CMS Rolls Out Nursing Home Risk-Based Survey Nationwide: New "High Performing Facility" Icon, Shorter Inspections, and the Criteria That Decide Who Qualifies

The Centers for Medicare & Medicaid Services (CMS) has directed all State Survey Agencies (SAs) to begin using a new, shortened inspection process for the nation's highest-performing nursing homes starting September 8, 2026. The change is laid out in a memorandum designated QSO-26-14-NH, titled "Nursing Home Risk-Based Survey National Implementation," issued July 16, 2026, by the Quality, Safety & Oversight Group (QSOG) and the Survey & Operations Group (SOG) within CMS's Center for Clinical Standards and Quality.

The memo formally launches the Risk-Based Survey (RBS) — a streamlined version of the standard nursing home recertification inspection — after three years of pilot testing in 22 states. It also introduces a new "High Performing Facility" icon that will appear on qualifying nursing homes' profile pages on the Medicare Nursing Home Care Compare website, and it sets out, in granular detail, the eleven criteria a nursing home must meet to qualify and the five circumstances that can disqualify it before a survey ever begins.

Nationally, CMS's own preliminary data show that just 1,560 of the country's 14,682 Medicare- and Medicaid-certified nursing homes — about 12% — currently meet the bar. Below, HealthBridge US walks through what the Risk-Based Survey is, why CMS built it, who qualifies and who doesn't, what changes for state survey agencies and nursing home operators, and what it means for residents and families choosing a facility.

Quick-Read Summary

Before the details, here is the essential rundown of what's changing. CMS will launch the Risk-Based Survey nationwide beginning September 8, 2026, allowing State Survey Agencies to conduct a shortened version of the standard nursing home recertification inspection — with a smaller survey team, roughly half the onsite time, and a smaller sample of residents reviewed — at nursing homes that meet a strict set of quality benchmarks. CMS estimates that approximately 12% of nursing homes nationwide, or 1,560 out of 14,682 total facilities, currently qualify, though that share varies enormously by state, from 0% in Alabama to nearly 31% in Hawaii. To qualify, a facility must hold a 5-star overall rating, a staffing rating of at least 3 stars, no citations for actual harm, immediate jeopardy, or substandard quality of care in its last survey cycle, a health inspection score in the better-performing half of its state, and clean results on several other data-integrity and ownership checks. CMS will send each State Survey Agency a quarterly list of qualifying facilities, and a facility can lose its RBS eligibility at any point before its survey begins if new complaints, citations, or ownership changes arise. Starting September 30, 2026, the public will be able to see which nursing homes qualify via a new trophy icon on each facility's Nursing Home Care Compare profile page. CMS frames the initiative as a way to redirect scarce survey resources — the federal nursing home survey budget has not increased since 2015 — toward facilities and complaints where residents face the greatest risk of harm.

Why This Matters Right Now

Nursing home oversight in the United States runs on a resource-constrained system. Federal law requires State Survey Agencies to inspect every Medicare- and Medicaid-certified nursing home at least once every 15 months using CMS's Long-Term Care Survey Process (LTCSP), a comprehensive, multi-day, multi-surveyor inspection protocol that CMS implemented in 2017. SAs are also required to investigate complaints of alleged noncompliance as they arise, using abbreviated versions of that same protocol.

According to CMS's own account in this memo, the federal budget allocated to nursing home surveys has not increased since 2015. Over that same period, State Survey Agencies' obligation to conduct complaint investigations has grown by more than 20%, on top of a decade's worth of ordinary cost-of-living increases in the price of running a survey operation. The result, CMS says, has been a growing backlog of Medicare- and Medicaid-certified nursing homes that have gone without their legally required standard survey, and reduced capacity for SAs to investigate complaints where residents may be at immediate risk.

That is the operational problem the Risk-Based Survey is designed to solve. Rather than spreading a fixed and shrinking pool of surveyor hours evenly across every nursing home regardless of track record, CMS wants to concentrate full-scale scrutiny on facilities with a history of problems, or with no recent survey at all, while allowing a lighter-touch review at facilities that have already demonstrated a strong compliance record. For an industry that has faced sustained public and congressional attention over staffing shortages, resident safety incidents, and uneven quality across the roughly 15,000 Medicare-certified nursing homes nationwide, this rule is notable less for any single technical provision than for what it signals: CMS is willing to formally differentiate its oversight intensity by facility performance, rather than apply a uniform inspection standard to every certified nursing home regardless of history.

Background: How We Got Here

State Survey Agencies conduct two main types of nursing home inspections. The first is the standard recertification survey, an unannounced, comprehensive inspection required at least once every 15 months under Sections 1819(g)(2)(A) and 1919(g)(2)(A) of the Social Security Act and 42 CFR 488.308(a) and (f). The second is the complaint investigation, triggered when CMS or a state receives an allegation that a facility is out of compliance with federal health and safety requirements. Both use the LTCSP, CMS's standardized inspection protocol, in full form for standard surveys and in abbreviated form for complaint investigations.

CMS states that it continually evaluates the LTCSP for ways to make nursing home oversight more effective and more efficient without compromising resident safety. That evaluation led, in 2023, to a pilot of the Risk-Based Survey process in 22 states and more than 100 facilities. According to the memo, the pilot's findings were "comparable to the traditional LTCSP" in identifying noncompliance and risks to resident health and safety, which CMS cites as the basis for expanding the process nationwide. CMS is explicit that the RBS is intended only for higher-performing facilities where the underlying risk to residents is already lower; the memo states plainly that "it is critical to perform the RBS only in higher-performing facilities where the risk to residents' health and safety is lower."

The Five-Star Quality Rating System, Briefly

Because so many of the RBS qualifying and disqualifying criteria are built directly on top of CMS's existing Five-Star Quality Rating System, it is worth understanding how that underlying system works before looking at the RBS criteria themselves. CMS has published Five-Star ratings for nursing homes since 2008 as part of the Nursing Home Care Compare website, and the rating is built from three separate component scores that combine into a single overall star rating for each facility.

The first component is the Health Inspection rating, drawn directly from a facility's most recent standard surveys and complaint investigation history, and weighted toward more recent survey cycles. The second component is the Staffing rating, which measures nurse staffing levels — including registered nurse hours and total nurse staffing hours per resident per day — relative to each facility's case-mix-adjusted resident population, drawing on the same Payroll-Based Journal data CMS separately audits for RBS purposes. The third component is the Quality Measures rating, based on clinical outcome and process measures drawn from resident assessment data and, for some measures, Medicare claims data, covering areas such as pressure ulcers, falls with injury, use of antipsychotic medications, and hospital readmissions.

The Health Inspection rating serves as the foundation of the overall Five-Star score, and the Staffing and Quality Measures ratings can adjust the overall score up or down from that baseline, subject to certain caps CMS applies to limit how far the Staffing and Quality Measures components alone can push a facility's rating. Because the RBS qualifying criteria pull independently from both the Overall rating and the Staffing rating — and separately impose a stricter, state-relative standard on the Health Inspection score specifically — a facility's path to RBS eligibility runs through several layers of the same underlying rating system rather than a single composite number.

What the Risk-Based Survey Actually Is

The RBS is not a separate regulatory category of inspection — legally, it is still a standard recertification survey as defined under the Social Security Act and 42 CFR 488.301. What changes is the execution. The RBS is a modified, streamlined version of the LTCSP that still reviews all the same required regulatory areas but with fewer discrete survey activities, a smaller sample of residents reviewed for compliance purposes, a smaller total survey team, and roughly half the onsite time of a traditional LTCSP survey.

In practical terms, a facility undergoing an RBS still receives a real, unannounced onsite inspection covering the full range of federal nursing home requirements — it is not a paperwork exercise or a desk review. The difference is scope and duration: SAs deploy fewer surveyors for less time, and examine a smaller cross-section of residents, on the premise that a facility with a strong, verified track record is statistically less likely to be concealing widespread noncompliance than a facility with an unknown or troubled history.

CMS's rationale for this differentiated approach is resource reallocation. By spending fewer surveyor-hours on facilities that have already demonstrated strong performance across a wide range of quality metrics, State Survey Agencies can redirect the surveyor time they save toward two priorities CMS identifies as more urgent: investigating complaints where residents may currently be at risk of harm, and working down the backlog of nursing homes that have gone without a legally required standard survey.

The RBS Qualifying Criteria: The Eleven-Point Bar

CMS's memo lays out, in Appendix A, the specific criteria CMS uses to build its quarterly list of RBS-qualified facilities. To qualify, a nursing home must not have any of the following eleven disqualifying conditions:

A facility cannot have less than a 5-Star Overall Rating on the CMS Five-Star Quality Rating System, and it cannot have a Staffing Rating below 3 stars. It cannot have received any citation for Actual Harm, Immediate Jeopardy (IJ), or Substandard Quality of Care (SQC) during its last survey cycle, which CMS defines as the facility's last standard survey plus any complaint investigations conducted within the preceding year. It cannot have gone more than 18 months without a standard survey, and it cannot currently have any staffing waivers in effect — a reference to the limited exceptions to federal staffing requirements that facilities may obtain under 42 CFR 483.35.

A facility is also excluded if it has failed a CMS audit of its Payroll-Based Journal (PBJ) staffing data, the system nursing homes use to report staffing hours to CMS, or if it has failed a CMS audit of its Minimum Data Set (MDS) resident assessment data. Both audits exist to verify that the data a facility reports to CMS — the same data that feeds into its Five-Star ratings — can actually be substantiated; a facility whose staffing or assessment data cannot be verified as accurate is not eligible for the lighter-touch review, regardless of what its reported numbers show.

Two further criteria are less commonly discussed but are built into the model. A facility is disqualified if its Health Inspection Score is worse than the 50th percentile within its state — that is, if it performs worse than the median nursing home in its state on the health inspection component of the Five-Star system, since a lower score indicates better performance under CMS's scoring convention. And a facility is disqualified if two or more of its long-stay residents aged 65 or older were coded with a new diagnosis of schizophrenia after being admitted without that diagnosis on record — a criterion tied to longstanding federal scrutiny of inaccurate schizophrenia coding in nursing homes, an issue regulators and watchdogs have flagged nationally because that diagnosis can affect a facility's official quality measures and because inaccurate psychiatric diagnoses in elderly residents raise separate care-quality concerns.

Finally, a facility cannot qualify if it has undergone a change in ownership since its last standard survey, and it cannot qualify if it is a Special Focus Facility candidate — CMS's designation for nursing homes with a documented, persistent history of serious quality problems that receive intensified federal oversight. CMS instructs State Survey Agencies to conduct the RBS strictly according to the lists CMS sends them and the disqualification criteria that apply at the time, rather than relying on what is publicly displayed on the Nursing Home Care Compare website, since there is a data-processing lag between the internal list and the public-facing site.

The Disqualifying Criteria: How a Facility Can Lose Its Spot Mid-Quarter

Qualifying for the RBS list is not a permanent designation. Appendix C of the memo sets out five circumstances that can disqualify a facility after it has already been placed on CMS's Quarterly Qualified List but before its actual RBS survey begins — and State Survey Agencies are required to check for these conditions immediately before conducting the survey.

A facility loses its RBS eligibility if it receives a citation for Actual Harm, Immediate Jeopardy, abuse at any level, or Substandard Quality of Care arising from an intake investigation that occurred while it was listed as RBS-qualified. It is also disqualified if it has any pending intake investigation that has been triaged at the Immediate Jeopardy level, or if it has more than three pending, non-Immediate-Jeopardy active intakes — meaning complaints or facility-reported incidents — that have been triaged as medium severity or higher. A facility with a CMS-approved nursing waiver, or one that has undergone a change in ownership since its last standard survey, is likewise excluded.

If a State Survey Agency finds that a facility meets any of these five disqualifying conditions, the memo is unambiguous: the SA "MUST convert the RBS to Long Term Care Survey Process standard survey." In other words, the streamlined inspection is not available as a matter of administrative convenience once new risk signals appear — the SA is obligated to fall back to the full, traditional inspection. CMS also preserves discretion above and beyond these fixed criteria: State Survey Agencies may voluntarily choose to conduct a full LTCSP survey at any RBS-qualifying facility if they have independent health or safety concerns, such as an unresolved complaint pattern that hasn't yet hit the formal disqualification threshold, and CMS itself may direct an SA to use the full LTCSP at a qualifying facility based on health and safety concerns or on the SA's own survey performance.

By the Numbers: Who Qualifies Nationwide

CMS included, as Appendix D of the memo, a state-by-state breakdown of qualifying and non-qualifying nursing homes as of June 2026, along with the specific reasons each non-qualifying facility was excluded. CMS is careful to frame this as preliminary data, subject to change as more recent facility information is incorporated once the program goes live, and notes that the reasons for exclusion are not mutually exclusive — a single facility can, and frequently does, fail more than one criterion simultaneously, which is why the individual exclusion-reason percentages do not sum to the overall non-qualifying rate.

Nationally, of 14,682 total Medicare- and Medicaid-certified nursing homes, 1,560 — 12.01% — currently qualify for the RBS. That leaves 13,122 facilities, or roughly 88% of the nation's nursing homes, that do not currently meet the bar.

Among facilities that fall short, the single most common reason is a Five-Star Overall Rating below 5 stars, which applies to 11,639 facilities, or 78.39% of all nursing homes nationwide — a reminder that the 5-star threshold alone excludes the large majority of the industry regardless of any other factor. A Health Inspection Score worse than the state median disqualifies 7,333 facilities, or exactly 50.05% nationally, which is close to definitionally expected given that the criterion is set at the state's own 50th percentile. A Staffing Rating below 3 stars affects 5,692 facilities (29.43%). Citations for Actual Harm in the last survey cycle affect 2,723 facilities (19.61%), a diagnosis of new post-admission schizophrenia coding in two or more older long-stay residents affects 2,867 facilities (15.22%), Immediate Jeopardy citations affect 1,674 facilities (11.54%), and Substandard Quality of Care citations affect 1,612 facilities (11.24%). Roughly 1,410 facilities (8.98%) have gone unsurveyed for more than 18 months, and 440 facilities (4.22%) are Special Focus Facility candidates. Smaller but still meaningful shares of facilities are excluded for a failed PBJ staffing-data audit (242 facilities, 1.84%), a failed MDS assessment-data audit (100 facilities, 0.38%), or an active staffing waiver (37 facilities, 0.28%). No facility nationally was excluded for a recent change of ownership in this preliminary count, according to the data in the memo.

The state-by-state variation is substantial. Several states currently have very few — or, in one case, no — RBS-qualifying facilities. Alabama has zero qualifying facilities out of 224 total nursing homes (0.00%), the only state in the dataset at that floor. Louisiana qualifies just 7 of 266 facilities (2.63%), Kentucky qualifies 10 of 268 (3.73%), and Missouri qualifies 22 of 487 (4.52%). Several large states also post relatively low qualification rates: Texas, the state with the second-largest nursing home count in the country at 1,176 facilities, qualifies only 59 of them (5.02%); Oklahoma qualifies 15 of 283 (5.30%); and Georgia qualifies 20 of 356 (5.62%).

At the other end of the spectrum, Hawaii has the highest qualification rate in the country, with 13 of its 42 facilities (30.95%) meeting the RBS bar. Alaska qualifies 4 of 20 facilities (20.00%), Wyoming qualifies 8 of 36 (22.22%), Washington qualifies 38 of 193 (19.69%), Montana qualifies 12 of 61 (19.67%), and North Dakota qualifies 14 of 72 (19.44%).

Among the largest states by facility count, California — with 1,164 total nursing homes, the most of any state — qualifies 180 facilities (15.46%), a rate above the national average. New York qualifies 57 of 596 facilities (9.56%), Ohio qualifies 72 of 921 (7.82%), Illinois qualifies 54 of 667 (8.10%), Florida qualifies 92 of 694 (13.26%), and Pennsylvania qualifies 88 of 656 (13.41%).

CMS notes in the memo that, beyond the Five-Star rating threshold itself, the most common reason facilities are excluded is a low staffing rating, which the data bear out as a major driver of exclusion in many states — a pattern consistent with broader, long-running national concerns about nursing home staffing adequacy.

Regional patterns are also visible in the underlying data, though CMS's memo does not offer an explanation for them. States in the Midwest and South with large total facility counts — Illinois, Missouri, Texas, Louisiana, and Oklahoma among them — generally post qualification rates below the 12.01% national average, often driven by a combination of low staffing ratings and above-median health inspection scores. Illinois, for example, qualifies 54 of its 667 facilities (8.10%), with 71.06% of its facilities excluded for a sub-3-star staffing rating alone — well above the 29.43% national rate for that criterion. By contrast, several smaller states and states with fewer total facilities — Hawaii, Alaska, Wyoming, North Dakota, and Montana — post qualification rates well above the national average, though CMS's data do not indicate whether that reflects genuinely stronger average performance, a smaller and more homogenous facility base, or some combination of both. Mid-sized states cluster closer to the national average: Michigan qualifies 73 of 423 facilities (17.26%), Wisconsin qualifies 42 of 323 (13.00%), and Maryland qualifies 37 of 221 (16.74%).
How the Quarterly List Process Works

CMS will not simply publish one national list and leave it in place indefinitely. Instead, CMS will generate and distribute a refreshed list of RBS-qualified facilities to each State Survey Agency at the end of every calendar-year quarter — March, June, September, and December — reflecting the most current facility performance data available at that time.

To receive access to their list ahead of scheduling any RBS surveys, State Survey Agencies were required to submit two designated email addresses to CMS's dedicated inbox, NHSurveyDevelopment@cms.hhs.gov, with the subject line "Access to the RBS qualified facilities list," by July 31, 2026 — a deadline that fell just after this memo's issuance and roughly five weeks before the September 8 nationwide launch.

Once a facility appears on a quarterly list, it remains eligible for the RBS for six months, unless it triggers one of the five disqualifying conditions described above in the interim. Before conducting any RBS survey, the SA is required to affirmatively confirm that the facility has not developed any disqualifying condition since it was placed on the list — the eligibility window does not run on autopilot.

Starting September 30, 2026, CMS will make the list of qualifying nursing homes publicly available through two channels: CMS's Provider Data Catalog and the Nursing Home Care Compare website, with updates on a regular, ongoing basis. CMS flags an important operational caveat here for State Survey Agencies: because of processing and data-transmission lag between CMS's internal list distribution and the public website update, the facilities shown as qualified on the public Care Compare site may not always match the list an SA has been working from at any given moment. The memo instructs SAs explicitly to schedule and conduct RBS surveys based on the list CMS sends them directly, together with the disqualifying criteria that apply at the time of the survey — not based on what happens to be displayed publicly on Care Compare on a given day.

Surveyor Training and Certification Requirements

Rolling out a new survey methodology nationwide requires training thousands of state surveyors across every SA in the country, and CMS has built a multi-month training schedule to support that. Comprehensive RBS training sessions will run through August and September 2026, combining recorded instructional material, hands-on practical exercises, and live interactive question-and-answer sessions. CMS is offering the training on multiple dates to accommodate the varying schedules of SAs and CMS regional offices nationwide.

Two core courses make up the curriculum. RBS-1 covers offsite preparation, the survey entrance conference, and the initial resident pool selection process, including the associated team meeting. RBS-2 covers sample finalization, investigations, facility-level survey tasks, and the process for the investigation and potential-citation team meeting, along with final reporting. Both courses are being offered together on three dates: Tuesday, August 18, 2026 (RBS-1 from 12:30 to 2:30 p.m. ET, RBS-2 from 3:00 to 5:00 p.m. ET); Tuesday, August 25, 2026 (same time blocks); and Tuesday, September 15, 2026 (same time blocks) — the last training date falling exactly one week before the nationwide launch begins reaching individual state survey schedules.

After the September 8 launch, CMS will continue supporting the rollout through live "office hours" calls where surveyors and SA staff can raise implementation questions directly with CMS, along with a permanent library of on-demand iQIES training videos, written user manuals, and supplementary materials hosted on CMS's Quality, Safety & Education Portal at qsep.cms.gov.

Each state bears direct responsibility for ensuring that all of its surveyors, and any relevant SA staff, complete the required RBS training before conducting RBS activity. This obligation extends to third parties: states that contract with outside agencies to perform survey work must ensure those contracted surveyors also complete the full required training curriculum before participating in any RBS survey.

CMS also built in a specific certification carve-out worth flagging for state survey leadership. Under standard practice, surveyors conducting nursing home inspections generally must hold Surveyor Minimum Qualifications Test (SMQT) certification. For RBS survey teams of two or fewer surveyors, that standard holds: all RBS surveyors on the team must be SMQT-certified. But if an RBS survey team requires more than two surveyors, the additional surveyors beyond the first two do not need to hold SMQT certification — though they are still required to have completed the full set of iQIES trainings covering both the LTCSP and the RBS specifically. In effect, CMS is giving states a limited staffing flexibility for larger RBS teams, provided the core surveyors are fully credentialed and every team member has completed the RBS-specific coursework.

Supporting all of this is a centralized Survey Resource Folder, which houses comprehensive documentation covering both the traditional LTCSP and the new RBS process — procedural guidance, standardized assessment tools, and checklists designed to help surveyors and nursing home staff alike work through compliance evaluation and documentation in a consistent, repeatable way. The RBS Procedure Guide and related materials are posted on CMS's nursing home guidance page.

The High-Performing Facility Icon and Nursing Home Care Compare

Perhaps the most visible change for the public is a new icon CMS will add to each qualifying nursing home's profile page on the Nursing Home Care Compare website — the same consumer-facing tool families already use to compare nursing homes on the Five-Star rating system. The icon, styled as a trophy, is meant to let consumers, family caregivers, discharge planners, and other stakeholders immediately identify facilities that meet the RBS's quality bar, giving them an additional data point beyond the existing Five-Star rating.

The icon is not a one-time badge; it is tied directly to a facility's ongoing eligibility status. It will remain visible on a nursing home's Care Compare profile page for as long as the facility continues to qualify for the RBS, and it will be removed once a facility is no longer eligible — whether because it fails to requalify on a subsequent quarterly list or because it is disqualified mid-cycle. Beyond the profile icon itself, CMS is building RBS visibility into several other public and semi-public data points: a footnote will appear on the Care Compare webpage displaying a facility's survey results whenever that survey was conducted using the RBS process rather than the full LTCSP; an indicator will appear directly on the facility's official survey report, form CMS-2567; and the RBS designation will also be reflected in the underlying survey files CMS posts to its Provider Data Catalog for Nursing Home and Rehab Services.

Taken together, this creates a layered transparency structure: a consumer glancing at Care Compare sees the icon; a more detailed reviewer checking the specific survey record sees the footnote and the CMS-2567 indicator; and researchers, journalists, or advocacy organizations working with the underlying open data can identify RBS surveys programmatically through the Provider Data Catalog.

What Changes Operationally for State Survey Agencies

Beyond the training curriculum and list-access logistics described above, State Survey Agencies face a broader operational adjustment in how they plan and staff their survey calendars. Under the traditional model, every certified nursing home in a state is scheduled for a standard survey on essentially the same cadence, and SA leadership allocates surveyor teams accordingly, with complaint investigations layered in as they arise. Under the RBS model, SAs must now maintain two parallel scheduling tracks: a traditional LTCSP track for facilities that do not qualify, have never been evaluated, or have been disqualified, and an RBS track for qualifying facilities, with the added requirement of a pre-survey eligibility check on every RBS-scheduled facility to confirm none of the five disqualifying conditions has arisen since the facility's placement on the quarterly list.

That pre-survey check is not a formality CMS treats lightly. Because a facility can be disqualified by events as recent as a newly triaged complaint, SAs will need some internal process — the memo leaves the specific mechanism to each state's own practice — to cross-reference a facility's current complaint and intake-investigation status against the disqualifying criteria in the days or hours before a scheduled RBS visit begins. The memo's language that "the Team Coordinator should follow their state practice to verify the above exclusions prior to RBS" suggests CMS is deliberately leaving the operational implementation of that check to each SA rather than mandating a single verification workflow nationally, which means the rigor of that pre-survey screening may vary somewhat from state to state.

SAs also retain meaningful discretion within the new system. Even for a facility that clears every qualifying and disqualifying criterion, an SA can still elect to conduct a full LTCSP survey instead of an RBS if it has independent concerns about a facility's health and safety record that haven't yet crossed a formal disqualification threshold — for instance, a pattern of lower-severity complaints that hasn't reached the three-complaint disqualifying trigger. CMS also reserves the right to direct an SA to use the full LTCSP at a nominally RBS-qualifying facility, whether for health and safety reasons or because of concerns about that SA's own survey performance, giving CMS a backstop against both facility-level and state-level risk that the automated qualifying criteria alone might not fully capture.

Timeline: What Takes Effect When

July 16, 2026 — CMS issues memorandum QSO-26-14-NH to State Survey Agency Directors, effective immediately, with instructions to communicate the memo to all appropriate staff within 30 days.

By July 31, 2026 — State Survey Agencies must submit two designated email addresses to CMS to gain access to their RBS-qualified facility list ahead of the nationwide launch.

August and September 2026 — CMS conducts nationwide RBS surveyor training, with RBS-1 and RBS-2 course sessions offered on August 18, August 25, and September 15, 2026.

September 8, 2026 — The Risk-Based Survey launches nationwide, with State Survey Agencies beginning to conduct RBS inspections at qualifying facilities according to their individual survey schedules.

September 30, 2026 — CMS begins publicly posting the list of RBS-qualified nursing homes on its Provider Data Catalog and on the Nursing Home Care Compare website, with regular ongoing updates and the new High Performing Facility icon appearing on qualifying facilities' profile pages.

Ongoing, quarterly (March, June, September, December) — CMS refreshes and redistributes the RBS-qualified facility list to each State Survey Agency, with individual facilities remaining eligible for six months from the date their SA receives the list, subject to the disqualifying criteria described above.

What This Means for Nursing Home Operators

For nursing home administrators and compliance staff, this memo is worth reading closely even for facilities that do not currently qualify for the RBS, since qualification status can change every quarter as new survey and complaint data come in. Facility leadership should first determine where their own building stands against all eleven qualifying criteria in Appendix A — not just the headline Five-Star Overall Rating, since a facility can hold five stars overall and still be excluded by a sub-3-star staffing rating, an above-median health inspection score relative to its state, an unresolved PBJ or MDS audit finding, or a pending Special Focus Facility designation.

Operators of facilities that do currently qualify, or that are close to qualifying, should treat the disqualifying criteria in Appendix C as an active, real-time compliance watch list rather than a one-time check. Because a citation arising from an intake investigation, a cluster of pending medium-or-higher complaints, or a change in ownership can strip RBS eligibility at any point up until a survey actually begins, compliance and risk-management teams should track open complaints and pending investigations with particular attention if their facility is on a current quarterly list, since the eligibility calculus can shift quickly and without much public warning.

Operators should also confirm that their facility's own reported PBJ staffing data and MDS resident assessment data are accurate and defensible, since a failed audit on either front is an independent bar to qualification regardless of a facility's clinical track record. Given that CMS has flagged inaccurate post-admission schizophrenia coding in older long-stay residents as one of its eleven qualifying criteria, facilities should also ensure their diagnostic coding practices for long-stay residents are clinically accurate and well documented, both because it affects RBS eligibility and because it is a documented area of federal scrutiny in its own right.

Finally, state-level provider associations and multi-facility operators may want to track their own state's qualification rate relative to the national 12.01% average using the state-by-state breakdown in Appendix D, since qualification rates vary widely — from zero facilities in Alabama to nearly a third of all facilities in Hawaii — and that variation likely reflects a mix of underlying quality differences and state-specific survey and staffing-data patterns worth understanding at an association level.

What This Means for Residents and Families

For residents, families, and the professionals who help them choose a nursing home — discharge planners, geriatric care managers, elder-law attorneys, and others — the most tangible near-term change is the new trophy icon that will begin appearing on Nursing Home Care Compare starting September 30, 2026. Families researching a facility will be able to see, alongside the existing Five-Star rating, whether that nursing home has independently met CMS's RBS qualifying bar: a 5-star overall rating, a staffing rating of at least 3 stars, a clean recent survey and complaint history free of the most serious citation types, a health inspection score better than the state median, and clean results on federal data-integrity audits.

It is worth understanding what the icon does and does not represent. Qualifying for the RBS means a facility met a specific, published set of quality thresholds as of CMS's most recent quarterly data pull — it is not itself a survey result, and a facility can lose the designation between quarterly updates if new complaints or citations arise. Families should also understand what an RBS survey itself involves if a facility they're considering has recently undergone one: it is a real, unannounced, comprehensive federal inspection covering the same required regulatory areas as a traditional survey, conducted with a smaller team over less onsite time and a smaller resident sample — not a lighter compliance standard, according to CMS, but a more efficient application of the same standard justified by the facility's already-demonstrated track record. Families can identify whether a specific survey was conducted using the RBS process by checking the footnote on the facility's survey results page on Care Compare.

Context and Open Questions

This memo does not exist in a vacuum, and it is worth situating within the broader, ongoing debate over nursing home survey capacity and quality oversight. CMS's own framing in this memo — that federal survey funding has been flat since 2015 while complaint-investigation obligations have grown by more than 20% — describes a resource squeeze that has been a recurring theme in nursing home policy discussions for years, echoed by state survey agencies, industry groups, and resident-advocacy organizations alike, even though those groups have often disagreed sharply about the right solution.

Supporters of a risk-based, differentiated survey model generally argue that treating every nursing home identically regardless of track record wastes scarce surveyor time on facilities that have already demonstrated strong, sustained compliance, at the direct expense of facilities with troubled histories or long-overdue surveys where residents may face real, current risk. From that vantage point, redirecting surveyor hours toward complaint backlogs and unsurveyed facilities is a more resident-protective use of a fixed budget than an unmodified, uniform inspection schedule.

Resident-safety advocates and some nursing home reform organizations have historically raised a different set of concerns about risk-based or abbreviated survey models in general, independent of this specific CMS program: that a smaller survey team, a smaller resident sample, and less onsite time create a narrower window in which problems can be identified, even at facilities with strong historical performance, since past compliance is not a guarantee of current conditions; that quality metrics like the Five-Star rating and staffing data have themselves been the subject of long-running debate over their accuracy and susceptibility to gaming; and that a public-facing icon signaling "high performance" could create a false sense of assurance for families if the underlying data driving that designation turns out to be stale, inaccurate, or unrepresentative of a facility's current day-to-day conditions. CMS's own inclusion of failed PBJ and MDS data-integrity audits as independent disqualifying criteria suggests the agency is aware of and attempting to guard against at least the data-accuracy version of that concern.

Whether the RBS strikes the right balance between resource efficiency and oversight intensity is likely to remain a subject of debate as the program scales from a 22-state, 100-facility pilot to a nationwide rollout covering thousands of qualifying facilities across all 50 states and the District of Columbia. CMS's own comparability findings from the pilot — that RBS results were comparable to full LTCSP findings in the tested facilities — are cited in the memo as the evidentiary basis for national expansion, though the memo does not include the full pilot evaluation methodology or results in detail.

The Bigger Picture

Read together, the elements of QSO-26-14-NH describe a CMS that is trying to do more oversight with a survey budget that, in real terms, has been shrinking for a decade. The Risk-Based Survey is CMS's attempt to make that shrinking budget stretch further by differentiating its inspection intensity according to a facility's demonstrated track record, rather than applying a single uniform standard to every certified nursing home regardless of history. The eleven qualifying criteria and five disqualifying criteria are, in effect, CMS's attempt to build a data-driven, defensible boundary around which facilities are lower-risk enough to receive the lighter-touch review — anchored not just in the well-known Five-Star rating but in staffing data audits, resident assessment data audits, diagnostic coding accuracy, ownership stability, and active complaint volume.

The new Care Compare icon extends that same logic to the public-facing side of the program: just as CMS is willing to formally differentiate its own survey resources by facility performance, it is now also willing to make that differentiation visible to the consumers choosing among nursing homes in their community. For an industry that operates under close public and regulatory scrutiny, and for the roughly two million Americans living in Medicare- and Medicaid-certified nursing homes at any given time, this rule is best read not as a reduction in oversight, but as a reallocation of it — one that CMS argues will let survey agencies spend more time where the data suggest residents are at greater risk, and less time re-verifying compliance at facilities that have already, repeatedly, demonstrated it.

Frequently Asked Questions

What is QSO-26-14-NH? QSO-26-14-NH is a CMS memorandum issued July 16, 2026, to State Survey Agency Directors, announcing the nationwide implementation of the Nursing Home Risk-Based Survey (RBS) beginning September 8, 2026.

What is the Risk-Based Survey? The RBS is a streamlined version of CMS's standard nursing home recertification inspection (the Long-Term Care Survey Process, or LTCSP). It reviews the same required regulatory areas but uses a smaller survey team, a smaller sample of residents, and roughly half the onsite time of a traditional survey, and is reserved for facilities that meet a defined set of quality criteria.

When does the Risk-Based Survey launch nationwide? September 8, 2026, based on individual State Survey Agencies' survey schedules.

How many nursing homes currently qualify for the RBS? According to CMS's preliminary June 2026 data, 1,560 of 14,682 nursing homes nationwide qualify, or about 12.01%. That share varies by state, from 0% in Alabama to nearly 31% in Hawaii.

What are the RBS qualifying criteria? A facility must have a 5-star overall rating, a staffing rating of at least 3 stars, no citations for actual harm, immediate jeopardy, or substandard quality of care in its last survey cycle, a standard survey within the last 18 months, no active staffing waivers, passing results on CMS's staffing (PBJ) and resident-assessment (MDS) data audits, a health inspection score better than the median in its state, no pattern of new post-admission schizophrenia diagnoses in older long-stay residents, no recent change in ownership, and no Special Focus Facility candidacy.

What can disqualify a facility after it's already on the qualified list? A citation for actual harm, immediate jeopardy, abuse, or substandard quality of care from an intake investigation; a pending intake investigation triaged at immediate jeopardy; more than three pending medium-or-higher complaints or incident reports; a CMS-approved nursing waiver; or a change in ownership. If any of these occur before the survey starts, the state must convert it to a full standard survey.

How long does RBS eligibility last? A facility remains eligible for six months after its State Survey Agency receives the quarterly qualified list, unless it triggers a disqualifying condition in the meantime.

What is the High Performing Facility icon? A new trophy icon CMS will display on the Nursing Home Care Compare profile page of every RBS-qualifying facility, beginning September 30, 2026, to help consumers identify higher-performing nursing homes.

How can I tell if a specific survey was conducted using the RBS? Through a footnote on the facility's survey results page on Nursing Home Care Compare, an indicator on the facility's CMS-2567 survey report, and in the underlying survey files posted to CMS's Provider Data Catalog.

Where can states get access to their RBS-qualified facility list? By emailing two designated contact addresses to NHSurveyDevelopment@cms.hhs.gov, the same inbox CMS designated for questions about the memorandum generally.

Where can I find the RBS training schedule and materials? RBS-1 and RBS-2 course sessions run August 18, August 25, and September 15, 2026, with materials, on-demand videos, and registration information available through CMS's Quality, Safety & Education Portal at qsep.cms.gov.

Is the Risk-Based Survey a lower compliance standard than a traditional survey? According to CMS, no — the RBS reviews the same required regulatory areas as the standard LTCSP survey and remains a legally standard recertification survey under 42 CFR 488.301. The difference is in scope and duration (fewer surveyors, less onsite time, and a smaller resident sample), which CMS says is appropriate given a qualifying facility's already-verified track record, not a relaxation of the underlying federal health and safety requirements being assessed.

Do all surveyors on an RBS team need special certification? All RBS surveyors must hold Surveyor Minimum Qualifications Test (SMQT) certification when the survey team has two or fewer RBS surveyors. If the team requires more than two surveyors, additional members beyond the first two are not required to be SMQT-certified but must have completed the full iQIES LTCSP and RBS training curriculum.

Can a facility request to be added to or removed from the RBS list? The memo does not describe a facility-initiated request process. Qualification and disqualification are determined by CMS based on the criteria in Appendices A and C, using facility performance, survey, staffing, and ownership data that CMS already collects.

Who signed the memorandum? QSO-26-14-NH was issued jointly by Karen L. Tritz, Director of the Survey & Operations Group, and Melissa Daly, Acting Director of the Quality, Safety & Oversight Group, both within CMS's Center for Clinical Standards and Quality.

This article is based on CMS memorandum QSO-26-14-NH, "Nursing Home Risk-Based Survey National Implementation," issued July 16, 2026, by the Directors of the Quality, Safety & Oversight Group and the Survey & Operations Group at the Centers for Medicare & Medicaid Services, including its Appendices A through D. For the complete memorandum and underlying facility-level data, stakeholders should consult CMS's official guidance at cms.gov and the Nursing Home Care Compare and Provider Data Catalog websites.

Reporting: HealthBridge US Policy Desk