‘Everyone Is Reevaluating’: Onerous Survey Process Is Latest Challenge to Operating Skilled Nursing Among CCRCs

Skilled nursing assets at continuing care retirement communities (CCRCs) have long been subject to downsizing for a variety of reasons, including operational challenges, the cost to care for skilled patients and regulatory hurdles. Add to this list: the severity of the nursing home survey process.

Stu Almer, CEO of Gurwin Healthcare System in New York, said the survey process for the nursing home environment is much more onerous and extensive than surveys of any other entities. In some cases, CCRCs have decided to simply partner with existing skilled nursing operators – rather than own their own SNFs – as costs and regulatory issues compound.

CCRCs are required to have a SNF referral option, but an organization doesn’t need to maintain their own physically, he said. Once the community downsizes to a 40- to 60-bed facility, they tend to stay at this number of beds as an option for existing residents currently in other care settings.


Not owning a SNF within the CCRC is part of a larger trend happening right now for any skilled nursing operator, he said.

“Everyone [in skilled nursing] is reevaluating,” he said, asking themselves if they should downsize, sell, or convert into some other type of housing.

“In assisted living, we’re also subject to regular surveys but not always annual, usually every couple of years,” said Almer. “Those of us on the SNF side, we typically will be visited by surveyors not just for annual surveys but upon any complaint investigation, any other concerns that may be reported to the state or any issues that arise.”


The state Department of Health is a “regular visitor” to the CCRC for SNF surveys, and it’s a different kind of visit, he said – more punitive. On the assisted living side, surveyors are a “greater comfort,” answering questions and issuing guidance.

Nicole Pretre, president and CEO of Cedar Community in Wisconsin, said the survey process for its skilled nursing consists of a team of four to five surveyors and can last several full days. Assisted living surveys, meanwhile, last only hours and involve one surveyor; there are no surveys for independent living in the state, she said.

California-based CCRC operators and state government entities are currently reevaluating the impact on business from skilled nursing surveys and discussed this as part of a panel for the LeadingAge meeting in California.

Repurposing skilled nursing beds, and turning certain areas into more independent apartments is a trend among those in the state, according to Darolyn Jorgensen-Kares, COO of Continuing Life.

On a national level, 44.5% of such communities in 2022 said they were looking to downsize their skilled nursing services on campus, according to a report published by CliftonLarsonAllen (CLA). The report estimates that skilled nursing would increasingly be offered as a service within the independent living arm of a CCRC within the next decade.

The SNF survey process is notorious

Surveys figure strongly in such reevaluations. While surveys may not directly lead to closures or downsizing, it affects quality of care, said Almer. The regulatory and survey process is so notorious that staff recruiting and retention is impacted too.

And, the survey processes are no different in a large-freestanding nursing home or a small skilled nursing wing in a CCRC, he said. The survey is the same, but a CCRC is less vulnerable when an incident occurs because it’s a small part of the whole business. But that also means that the SNF wing is more dispensable, especially if it means reducing burdens among staff.

Oftentimes adding to survey challenges is the lack of coordination between surveyors for a particular complaint in a CCRC, especially if it spans multiple care settings on a campus. In terms of complaints, it depends on when the allegation actually took place, said Pam Gill, assistant program administrator for the Northwest field operations, California Department of Social Services (CDSS).

If a resident was in a SNF two years ago when the violation occurred, then it would be the Department of Public Health (DPH) as opposed to the Department of Social Services (DSS) within a given state, she said.

When leaders of a CCRC and the DSS look at financial stability, they take into consideration the diversity of care settings, said Jorgensen-Kares. Meaning, they are looking at these diverse revenue streams and if it’s worth costs associated with certain services.

Regardless, budget and monthly fees are always hot topics, and skilled nursing is often at the top of the list in terms of cost and potential fees or civil monetary penalties (CMPs).

Coordination and collaboration for surveys

Part of the headaches specifically related to survey oversight of SNFs at CCRCs has to do with the collaboration process – or lack thereof – between the different entities involved. There are a lot of different government agencies that get involved in a complaint, especially if the resident experiences a care transition on campus.

When that collaboration fails, there’s often additional administrative burdens placed on staff within the CCRC.

Crossover with surveyors and government departments can happen if the complaint was during a time when the patient is transitioning out of one care setting to another, or the level of care was misrepresented, Gill said.

DSS handles other complaints outside of the heavily regulated skilled nursing sector in California.

In New York, Gurwin really doesn’t see much collaboration between these entities, but the DPH is the main government agency they work with for long-term care, and their standards usually exceed federal standards for the sector.

“You have the Department of Environmental Conservation, you may have OSHA with their own sets of standards. If you follow the Department of Health regulations, there’s a good likelihood you’ll be in compliance with, for the most part, all regulations,” said Almer.

Pretre doesn’t see much collaboration between these agencies either, but sometimes surveyors and ombudsmen will work together.

Almer said Gurwin staff works hard to develop a more collaborative relationship with regulators, but it’s just more challenging on the skilled nursing side. Both nursing homes and assisted living are surveyed on the same aspects, including quality of care and physical environment, he said.

For independent living, there’s no care provision there, Almer noted.

“Those surveys tend to be more financial in nature, making sure that people are billed appropriately, [they’ve] collected deposits,” said Almer. New York in particular is very heavily regulated when it comes to financial accountability on the independent living side, but it’s still a very different process from surveys that exist in nursing homes and assisted living.

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