As we begin a new year, there is benefit in evaluating lessons learned in 2019 to establish improvement goals for 2020. As you know, both annual surveys and complaint surveys can have a significant impact on the overall 5-Star Rating. To help guide action planning, let’s review the top 3 citations of 2019 and strategies for avoiding these citations in 2020.


Top 3 Citations Calendar Year 2019

  1. F880 Infection Prevention & Control
  2. F689 Free of Accident Hazards/Supervision/Devices
  3. F812 Food Procurement, Store/Prepare/Serve Sanitary


Recommended Strategies

    • (1) The LTC Survey Pathways are an excellent resource for training and on-going compliance monitoring in these high-deficiency rate areas.
      • The Infection Prevention, Control, & Immunizations Pathway (CMS-20054) is used to assess your compliance with F880 Infection Prevention & Control
      • Dining Observation (CMS-20053) and Kitchen Observation (CMS-20055) are pathways that surveyors will use during every annual survey to assess your compliance with F812 Food Procurement, Store/Prepare/Serve Sanitary requirements.
      • The Accidents Critical Element Pathway (CMS-20127) is a pathway that is triggered for use to further investigate if there are concerns identified in the care areas of accident hazards, falls, resident to resident interactions, smoking, or unsafe wandering/elopement to assess compliance with F689 Free of Accident Hazard/Supervision/Devices.

Facilities should establish processes to use the LTC Survey Pathways tools routinely to monitor compliance with these top cited F-Tags. If concerns are identified through the routine monitoring, the concerns should be reviewed with the QAPI committee and performance improvements plans implemented to address the identified concerns

    • (2) A mock survey is also an invaluable process that should be used by all SNFs. A Mock Survey provides the opportunity to take a fresh look at systems, procedures and processes of care to identify potential risk  areas. These risk areas can then be addressed through your performance improvement processes. The Mock Survey also provides the opportunity to “test” how your staff will perform and handle the stress associated  with surveys, as well as how your residents are likely to respond to the interviews conducted by surveyors.

Consider scheduling a Mock Survey to be conducted by external reviewers for a fresh and objective perspective and to maximize the benefits of the Mock Survey process. Proactive Medical Review & Consulting offers mock survey services to assist providers in preparing for the annual survey process by identifying potential areas that may be at risk related to your systems, procedures and processes of care, as well as consultation related to developing a plan of correction, follow-up compliance visits, staff training, and on-going regulatory compliance support services.


Proactive Medical Review specializes in assisting facilities with Five-Star Rating Improvement plans and preparing providers for the LTC Survey Process. Contact us today for more information regarding our proven Five-Star Improvement partnerships and survey preparedness projects.

Contact Proactive for abuse prevention and response training or for a comprehensive review of your existing program and processes



Blog by Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, Proactive Medical Review

Learn more about Shelly and the rest of the Proactive team.