Beyond the Five-Star Rating: What CMS’s Risk-Based Survey Recognition Means for Nursing Home Leaders

October 20, 2026

Why Survey Performance, QAPI, Workforce Stability, and Continuous Readiness Matter More Than Ever

Insights from Colleen Toebe, MSN, CWCN, RAC-MTA, RAC-MT, DNS MT
Vice President of Clinical Services, Pathway Health

With the nationwide implementation of the Risk-Based Survey (RBS) process underway, the Centers for Medicare & Medicaid Services (CMS) has introduced another important development for nursing home leaders: public recognition of facilities that qualify for this focused survey approach.

In its revised September 29, 2026 memorandum, QSO-26-14-NH, CMS confirmed the addition of a high-performing facility icon to Nursing Home Care Compare beginning October 8, 2026.

While this designation offers greater visibility for qualifying facilities, it also reinforces an important leadership principle: Sustained quality performance depends on more than favorable ratings or successful surveys. It requires strong clinical systems, workforce stability, accurate data, and continuous quality improvement.

What Do RBS Recognition and the High-Performing Facility Icon Really Mean?

CMS estimates that approximately 12% of nursing homes nationwide initially qualify for the RBS process. The high-performing facility icon, displayed as a trophy on Nursing Home Care Compare, identifies facilities that meet CMS’s established RBS qualification criteria.

Unlike an overall Five-Star rating, this designation reflects a broader set of performance and compliance considerations, including:

  • Five-Star Quality Ratings and staffing performance.
  • Health inspection results, survey history, and severity of deficiencies.
  • MDS and Payroll-Based Journal (PBJ) data accuracy.
  • Other specified quality, regulatory, and operational criteria.

The icon provides an additional point of reference for residents, families, referral partners, and other stakeholders evaluating nursing home performance. However, it is not a separate quality rating, an endorsement of a facility, or a guarantee of future survey outcomes.

Importantly, qualifying for RBS does not guarantee that a facility will receive a focused survey. CMS provides updated eligibility lists to State Survey Agencies quarterly, and qualifying facilities may become ineligible when specified disqualifying conditions occur.

For leaders, the goal should not simply be to earn or retain the icon. It should be to sustain the practices and outcomes that support quality care and regulatory compliance.

The Critical Connection Between Surveys and QAPI

Survey performance plays a significant role in RBS eligibility. A facility’s history of deficiencies, severity of findings, and regulatory compliance provides important information about potential risks to resident health and safety.

Although RBS uses a more focused survey process for qualifying facilities, it does not reduce federal health and safety requirements. Surveyors continue to evaluate compliance, and concerns identified during a focused survey may warrant expanded review. Complaint and facility-reported incident investigations also remain essential components of regulatory oversight.

For nursing home leaders, survey results should be viewed as more than a regulatory outcome. They are an important source of information for the organization’s Quality Assurance and Performance Improvement (QAPI) program.

Survey findings, complaint investigations, incident trends, internal audits, and quality measures can help leadership teams identify patterns, evaluate root causes, and determine whether corrective actions are producing sustainable improvements.

Consider a recurring fall-related concern. Addressing the immediate deficiency or updating a policy may be necessary, but meaningful improvement requires evaluating the underlying systems. Are resident risks being reassessed? Are interventions communicated across shifts? Are staff consistently implementing care plans? Are leaders monitoring whether corrective actions are effective?

The same approach applies to infection prevention, medication management, resident rights, staffing, and other areas of regulatory risk.

As emphasized in Pathway Health’s article, “Falls Prevention: Take a Fresh Look at the Systems Behind the Fall,” the objective is to look beyond individual events and evaluate the systems that influence outcomes.

Effective QAPI transforms survey findings and performance data into actionable improvements—not simply completed plans of correction.

Workforce Stability Is Part of Sustained Quality Performance

Staffing performance is another important consideration in RBS eligibility, making workforce recruitment and retention essential leadership priorities.

Adequate staffing levels matter, but so do workforce stability, competency, communication, and consistency in resident care.

High turnover can disrupt continuity, increase orientation and training demands, and create challenges with documentation, care plan implementation, and interdisciplinary communication. Conversely, a stable, well-supported workforce can strengthen the consistency of care practices and support ongoing quality improvement.

Nursing home leaders should evaluate retention strategies alongside staffing metrics, including:

  • Strengthening onboarding, mentoring, and competency development.
  • Supporting frontline managers and creating opportunities for professional growth.
  • Monitoring turnover, employee feedback, scheduling practices, and workforce trends.
  • Promoting a culture where staff concerns and resident care observations are heard and addressed.

These efforts support more than staffing performance. They help establish the operational consistency necessary for resident safety, quality outcomes, and survey readiness.

Moving From Survey Preparation to Continuous Readiness

RBS recognition provides an opportunity for leaders to reconsider how survey readiness is integrated into daily operations.

Rather than treating survey preparation as a periodic activity, organizations should establish processes that continuously evaluate clinical practices, documentation, staffing, and regulatory compliance.

This includes reviewing survey trends, conducting targeted audits and mock surveys, validating MDS and PBJ data, strengthening staff competencies, and using QAPI to monitor whether improvement strategies are effective.

Three questions can help guide leadership discussions:

Are we learning from our survey findings? Look beyond individual citations to identify recurring issues, contributing factors, and opportunities for system improvement.

Are our quality improvement efforts producing sustainable results? Evaluate whether corrective actions are implemented consistently, monitored over time, and adjusted when necessary.

Are our workforce strategies supporting consistent, high-quality care? Assess staffing stability, retention, competency, and the ability of interdisciplinary teams to carry out established care processes.

These considerations apply to every nursing home, regardless of current RBS eligibility.

How Pathway Health Can Help

Pathway Health partners with nursing home leaders to evaluate clinical and operational systems, identify regulatory vulnerabilities, and translate survey findings and quality data into practical improvement strategies.

Our experienced consultants can support organizations through:

  • Survey Readiness and Mock Surveys: Evaluate clinical practices, documentation, regulatory compliance, and high-risk areas through focused reviews and customized mock surveys.
  • QAPI and Performance Improvement Support: Analyze survey findings, quality indicators, and incident trends; identify root causes; and strengthen action planning, implementation, and monitoring.
  • Five-Star and MDS Assessments: Review quality measure performance, assessment accuracy, supporting documentation, and opportunities to strengthen data integrity.
  • Workforce and Leadership Support: Evaluate staffing processes, strengthen onboarding and competency development, and support leadership strategies that promote employee engagement and retention.
  • Regulatory Education and Mentoring: Provide practical training and guidance to help interdisciplinary teams maintain consistent, compliant care practices.

Our approach extends beyond identifying gaps. We work alongside leadership teams to strengthen the systems, processes, and accountability needed to support sustainable improvement.

Complimentary Resource: RBS Leadership Checklist

Is your organization evaluating its RBS eligibility and ongoing survey readiness?

Pathway Health’s Risk-Based Survey Leadership Checklist provides a practical resource to help nursing home leaders review key performance indicators, identify potential vulnerabilities, and support discussions about regulatory readiness and continuous improvement.

Access the RBS Leadership Checklist > 

The Leadership Takeaway

The introduction of CMS’s high-performing facility icon brings greater visibility to organizations that meet RBS qualification criteria. But recognition is only one part of the story.

The real measure of sustained performance is how effectively an organization uses survey findings, quality data, workforce strategies, and QAPI to strengthen care every day.

Whether your facility currently qualifies for RBS or is working toward stronger performance, now is an opportunity to evaluate existing systems, address vulnerabilities, and reinforce a culture of continuous improvement.

 

Strengthen Your Quality Performance. Sustain Your Survey Readiness.

Connect with Pathway Health to learn how our team can support your clinical, operational, workforce, and regulatory goals.

CMS Resources and Related Reading
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