More After-Hours Nursing Home Surveys Coming Under Updated CMS Guidance

What You Need To Know

The Centers for Medicare & Medicaid Services has issued updated nursing home surveyor direction through a revised CMS surveyor memo and updates to the State Operations Manual, reinforcing expectations around after-hours surveys, survey team composition, and enforcement practices. CMS publishes this guidance within the State Operations Manual Appendix PP for nursing homes, which surveyors use when assessing compliance.
CMS is standardizing the use of evening, overnight, and weekend survey starts so surveyors can observe real-world staffing and care delivery. While off-hours surveys have long been permitted, CMS is now emphasizing more consistent application across states, including Ohio.
The guidance reaffirms that an RN must be included on all initial and recertification survey teams and that surveyors must meet minimum qualification requirements before conducting surveys independently, as outlined in CMS surveyor qualification standards within the State Operations Manual.
CMS is also strengthening expectations for plans of correction, citing recommendations from the HHS Office of Inspector General related to inadequate corrective actions following serious deficiencies.

What Happens Next

CMS is reorganizing surveyor instructions by moving Immediate Jeopardy definitions, decision-making criteria, and examples into Chapter 7 of the State Operations Manual, consolidating guidance that was previously spread across multiple sections. This includes clearer examples tied to unsafe discharges and failures in care transitions.
In Ohio, the Ohio Department of Health conducts federal nursing home surveys under this CMS guidance, meaning Ohio facilities should expect more uniform survey processes and less flexibility around survey timing.
Survey team composition will increasingly reflect a facility’s complaint history and prior noncompliance, with clinical or specialty expertise added as CMS deems necessary.
All changes take effect March 30, 2026, and will apply to standard, complaint, and revisit surveys conducted in Ohio.

What to Do

Prepare leadership and clinical teams for unannounced off-hours survey entry, including weekends and overnight shifts, ensuring documentation, staffing plans, and supervisory coverage are consistent at all times.
Reevaluate discharge planning and transition practices, particularly where residents move to community settings, as CMS has indicated unsafe discharges may trigger Immediate Jeopardy investigations under the revised guidance.
Strengthen plans of correction to clearly document root causes, system-level fixes, measurable timelines, and monitoring processes, aligning with CMS expectations described in the State Operations Manual plan-of-correction requirements.
Confirm alignment with both federal CMS requirements and applicable Ohio Administrative Code nursing home staffing and operational rules, recognizing that Ohio surveyors will apply CMS guidance more consistently moving forward.