What the severity letters A to L mean

Every citation in a nursing home inspection report carries a letter from A to L. The letter combines two things inspectors decide after finding a problem: how serious the effect on residents was (severity), and how many residents were or could have been affected (scope). Severity runs from level 1 to level 4, and scope from isolated to widespread, giving a grid of 12 letters. This page explains that grid and the other labels that appear next to each citation in CMS data.

The grid, with Texas counts

Immediate jeopardy: immediate jeopardy to resident health or safety. Actual harm: actual harm (not immediate jeopardy). Potential for harm: no actual harm, potential for more than minimal harm. Minimal harm potential: no actual harm, potential for minimal harm. Counts are Texas citations in the current CMS data (32,724 in all). 90% are at the D–F level; 7% at J–L.

The four severity levels

A, B, C: No actual harm, with potential for minimal harm

Severity level 1. The problem could cause no more than a minor negative impact on residents, and no one was harmed. CMS still considers the home to be in substantial compliance with the requirement.

D, E, F: No actual harm, with potential for more than minimal harm

Severity level 2. No resident was actually harmed, but the problem could have led to more than minimal harm, short of immediate jeopardy. Most citations in the current Texas inspection data fall in this level.

G, H, I: Actual harm that is not immediate jeopardy

Severity level 3. The problem resulted in actual harm to one or more residents, but did not rise to the level of immediate jeopardy.

J, K, L: Immediate jeopardy to resident health or safety

Severity level 4, the highest level. The home's noncompliance caused, or was likely to cause, serious injury, harm, impairment, or death to a resident, so immediate corrective action was needed.

Scope

Isolated (A, D, G, J)

One or a very limited number of residents were affected or staff were involved, or the situation happened only occasionally or in very few locations in the home.

Pattern (B, E, H, K)

More than a very limited number of residents were affected or staff were involved, the situation occurred in several locations, or the same residents were affected repeatedly, but it was not pervasive throughout the home.

Widespread (C, F, I, L)

The problem was pervasive in the home or reflected a systemic failure that affected, or could affect, a large portion or all of the residents.

Correction status

CMS records a status for every deficiency. Here is what each value means and how many Texas citations have it.

"Deficient, Provider has date of correction" (31,632)

The home was cited for this problem, and CMS's data lists a correction date for it. Most citations have this status.

"Past Non-Compliance" (830)

The problem happened after the home's previous standard inspection, and the home had already corrected it and was back in compliance before the current inspection. CMS still records it as a citation with its own severity letter, but no plan of correction is required because the fix was already in place.

"Deficient, Provider has no plan of correction" (159)

The home was cited, and no plan of correction is recorded for this citation in CMS's data. This status mostly appears on inspections from the last few months.

"Deficient, Provider has plan of correction" (87)

The home was cited and has a plan of correction on file explaining how it will fix the problem. This status mostly appears on recent inspections.

"Waiver has been granted" (14)

An exception (waiver) to this requirement was approved for the home. In Texas records, this status appears only on F912, the minimum bedroom size rule, which federal rules allow the state survey agency or CMS to vary in individual cases.

"No revisit needed" (2)

The citation is on record, and CMS's data shows that no follow-up (revisit) inspection was needed for it. This status is rare in Texas records and has appeared only on level B and C citations.

Disputed citations (IDR and IIDR)

Citation under IDR means the home is disputing the citation through Informal Dispute Resolution. After receiving the official inspection report (Form CMS-2567), a nursing home can ask the agency that inspected it to informally reconsider specific cited deficiencies. Citation under IIDR means the citation is in Independent Informal Dispute Resolution, an additional review by an entity independent of the state survey agency, available when CMS imposes a civil money penalty that is placed in escrow. Depending on the outcome, a disputed citation may stay as written, have its findings or severity changed, or be deleted.

Standard and complaint inspections

A standard inspection (also called a recertification survey) is the periodic, unannounced, comprehensive inspection every certified nursing home receives, no later than 15 months after the previous one, with a statewide average interval of no more than 12 months. A complaint inspection is a narrower visit focused on a specific concern, such as a complaint the state received. When the two take place together, a citation may be marked as both.

• Level A citations (isolated, minimal potential for harm) are not listed on the official statement of deficiencies, so they rarely appear in CMS data.
• When findings for the same requirement vary, inspectors generally assign the highest severity level they found.
• In certain areas listed in federal rules, including quality of care, quality of life, and freedom from abuse, citations at F, H, I, J, K, or L are classified by CMS as substandard quality of care.
• Past non-compliance citations are assigned a scope and severity letter like other citations; in current Texas data some are at immediate jeopardy levels.
• Citations under IDR or IIDR, and citations from older (third-cycle) standard inspections, are included in CMS's data but are not used in its health inspection star rating.