Skilled nursing providers should be especially on alert for F-tags related to chemical restraints, and should also be prepared to have some difficult conversations to ensure survey success in the current environment.

These were a few takeaways that leaders with Brickyard Healthcare and Majestic Care shared this week at the Skilled Nursing News RETHINK Conference in Chicago. Indiana-based Brickyard Healthcare operates 23 facilities in the state. Majestic Care operates 42 properties across Indiana, Ohio and Michigan, and 10 for its Bluegrass Consulting Group in Kentucky.

While the most recent survey changes – which took effect in April 2025 – weren’t as numerous as in previous years, proving that a decision was the right one through documentation has been one challenge, said Brickyard Healthcare Chief Clinical Officer Lisa Chubb.

Today, Brickyard is in a “good place,” but one of the biggest challenges related to the new survey requirements involved “bridging the gap” while the company’s electronic health record system caught up with the changes, she noted.

“Our first go at [the packet] to check all the boxes of the requirements was like 108 pages,” she said. “There’s not a nurse alive that’s standing at a nurse’s station with a working printer and printing 108 pages.”

While Majestic Care has been implementing education strategies since November, now is the time for medical directors to be more accountable for their actions, considering the regulatory provisions that rely on medical director participation.

“It’s our responsibility for them to practice a certain way, and that’s difficult when you’re talking to clinicians,” said Dr. Robert Russell, chief medical officer, Majestic Care. “You’re trying to tell them how to actually show that they’re providing efficient care for the residents … that became something put squarely into focus for us, along with making sure that our care team members felt comfortable having those conversations, because that’s a difficult conversation to have with a medical director.”

Rise in chemical restraint citations

With regard to trends in F-tag citations since the April survey changes, Chubb highlighted chemical restraints. Surveyors are scrutinizing the discharge, transfer and voluntary discharge process a lot more, as well, but that hasn’t necessarily led to citations, she said.

Chubb described a recent case in which the chemical restraint was diligently documented except for one day; a citation was given for a lack of documentation around that day, despite a longer timeframe showing the medication was effective and needed.

“The general public is going to see [that] an operator is chemically restraining people in a building. They don’t realize it was a lack of documentation in one instance that had occurred,” said Chubb.

Highly involved medical directors, good documentation and talking through situations involving discharge, transfers and voluntary discharge is top of mind at Brickyard.

Majestic hasn’t seen an uptick in certain citations, but the organization has been getting a warning from surveyors if a facility’s documentation doesn’t line up with the documentation from other providers involved in the patient’s care in the SNF.

“[Providers] can no longer be siloed and come in and just practice medicine, because a lot of them don’t know how to practice medicine in this space,” Russell said. “You’ve got a nurse practitioner that just graduated, who just joined a provider group, who is coming into your building, who’s never been in a geriatric space other than being in classes and clinicals. They don’t understand your regulation. We’ve had to talk to hospice companies. They don’t understand our regulations.”

Russell believes that certain providers serving SNF and long-term care populations became less involved in resident care during the Covid-19 pandemic, and now this has become an issue that has to be addressed.

“Providers used to be a little more integral in things, but they’ve been allowed to be hands off,” Russell said. “I’m going to come and see my 10 patients, and peace, I’m out, call the on-call nurse, don’t call me. … That’s a problem. We’ve got to get them more involved.”

Brickyard has brought all staff roles into a survey education program called “Through the Eyes of the Surveyor,” which takes a “see something, say something” approach. If a social worker sees something wrong with a catheter that could be a regulation breach, the social workers are taught to bring that up.

“We teach everyone, from the medical director all the way down, all the way up, all the way across, so that we’re covering those things,” Chubb said. “We’ve actually seen year-over-year improvement with survey citations. In 2020, about 44% of our citations were in observational tags … it’s down to less than 20% today.”

Bridging the gap with inexperienced surveyors

Russell and Chubb touched briefly on surveyor education too – namely, that surveyors still are coming in inexperienced because of a workforce shortage among their ranks.

It’s been a learning experience for seasoned nursing staff in the facility, trying not to be overly confrontational or adversarial while working to get the best outcome, Russell said.

“That’s a big challenge … young surveyor [and] grizzled, seasoned nurse trying to navigate those waters,” said Russell. Adding additional complexity: the mentality among some surveyors that they have to “tag something,” since they’ve been out of the buildings for so long.

Chubb echoed the need to educate new surveyors, including on the point system and star ratings, with many new surveyors unaware that there are a certain number of points associated with different citations.

“It’s very impactful,” Chubb said of star ratings and points tied to citations. “It’s how our peers, how everyone looks at us, and so we take every advantage and opportunity to educate them.”

Chubb and other executives with Brickyard meet with the head deputy director of the state and talk through a lot of this type of education to be brought down to the individual surveyor, along with the subjectivity of surveys in certain areas.

“We definitely sit down and we bring the regulation to them and say, ‘Please show me where we missed on this, because I’m not seeing it.’ We try to walk through that with them. You have to educate them as well,” said Chubb.