Who actually does it
CMS sets the requirements, but the surveys are carried out by each state's own survey agency under agreement with CMS. Trained surveyors — typically nurses and other health professionals — spend several days on site.
That structure is the reason cross-state rating comparison does not work. Different states run their survey agencies with different staffing, caseloads, and backlogs, and CMS additionally scores the inspection domain relative to other facilities within the same state. Two identical facilities in different states can end up with different stars.
It is unannounced, and that is the point
A standard recertification survey arrives without notice. The facility does not know the date, which is what makes the findings meaningful — surveyors see the building as it normally runs rather than as it can be presented.
Federal rules also bound how long a facility can go between standard surveys, and CMS publishes the current requirements and each facility's survey dates. The dates matter when you read a record: a citation from a survey two months ago and one from three years ago describe different things, even when they carry the same severity letter.
Two routes an inspection arrives by
A standard survey is the routine comprehensive inspection — the whole facility, across care, safety, resident rights, medication handling, infection control, and more.
A complaint investigation is separate and targeted. Someone — a resident, family member, or staff member — reports a specific concern, and surveyors investigate that allegation. It is narrower in scope, and a citation arising from one means a concern was raised and at least partly substantiated.
Facility pages here label which route each citation came from, because the distinction changes what a finding implies. Separate fire-safety surveys also exist and are recorded apart from the health inspection.
What surveyors actually do on site
Surveyors observe care as it happens — meals, medication rounds, transfers, how call lights are answered — rather than relying on what records say. They interview residents and families, speak with staff, and review clinical records against what they observed.
Where the facility does not meet a federal requirement, they record a deficiency, which becomes a citation with a scope-and-severity letter indicating how serious it was and how many residents it reached. The facility then submits a plan of correction and is re-checked.
Why it dominates the rating
CMS builds the overall star rating by starting from the health-inspection rating and then adjusting it using staffing and quality measures. Inspection is not one of three equal inputs — it is the anchor.
That is worth knowing when a facility's components disagree. A strong staffing star sitting beside a weak inspection star usually produces a middling overall rating, and the inspection history is where the substance of that record lives. Our guide on reading citations explains the severity letters that make it legible.