Measure guide · SNF / CMS survey risk

Survey Risk Performance — Measure Guide

Complete write-up of every measure on the Survey Risk Performance board — in skilled nursing / CMS survey language operators and quality leaders already use. Explains what each metric means on the floor, how it is calculated, and where it appears.

Source: CMS Provider Data Catalog health citations + survey summary + SOD (2567) narrative join · Not a CMS Five-Star product · Internal risk weight is prioritization only

SNF Citations Spine (data product) API Doc

Core concepts

Facility (CCN)
CMS Certification Number — the unique ID for a skilled nursing facility (SNF) / nursing home provider. Filters and scorecards hang off CCN.
Health citation (deficiency)
One row from the CMS health citations extract: a survey finding with an F-tag (or other prefix), scope/severity letter, correction status, and standard/complaint/IC flags.
Survey event
A distinct facility + survey date combination. One survey can generate many citations. Operators care about both “how many findings” and “how many surveys.”
Scope & severity (S/S)
CMS letter A–L on each citation. Letters roll into bands: no actual harm (A–C), potential for more than minimal harm (D–F), actual harm (G–I), Immediate Jeopardy (J–L).
F-tag / deficiency category
Regulatory tag (e.g. F689) and QAPI-style deficiency category from CMS. Used for systems view, not as a substitute for S/S severity.
2567 / SOD narrative
Statement of Deficiencies inspection text from CMS SOD files, joined to the citation spine (CCN + date + tag). Previewed on the Facilities page for operator drill.
Not Five-Star
This board does not compute CMS Five-Star Health Inspection scores. Published star ratings may appear as context on facility scorecards only. Internal risk weight is a separate prioritization tool.

Rolling 12-month (R12) window

Most portfolio KPIs use a rolling 12 months ending at the latest survey date in the model (not “today” and not calendar year). That matches how quality teams talk about “the last survey cycle year” when CMS extracts lag the calendar.

Shared R12 variables (every R12 measure)

AsOf   = MAX ( FactHealthCitation[SurveyDate] )  across the whole table
StartD = AsOf − 365 days
Include rows where SurveyDate > StartD and SurveyDate ≤ AsOf

As Of Date surfaces that max survey date so users know the window. Example snapshot used in demos: as-of 2026-05-20 → window roughly 2025-05-21 through 2026-05-20.

MeasureOperator meaningCalculation
As Of Date Latest survey date loaded — the right edge of R12. CALCULATE ( MAX ( SurveyDate ), ALL ( FactHealthCitation ) )

Volume & footprint

MeasureWhat it tells a DON / QAPI leadCalculation
Citations All health citations in filter context (any date). COUNTROWS ( FactHealthCitation )
Citations R12 How many findings hit in the last 12 survey months. Portfolio heat. Count of citation rows in the R12 window.
Facilities R12 How many distinct SNFs had at least one citation in R12. DISTINCTCOUNT ( CCN ) in R12.
Survey Events R12 How many surveys (facility×date), not how many tags. Avoids counting five F-tags as five surveys. Count rows of SUMMARIZE on CCN + SurveyDate for citations in R12.
Cit per Survey R12 Average findings per survey event — survey “heaviness.” Citations R12 ÷ Survey Events R12
Providers Facilities in the provider dim (model universe), not limited to R12 activity. DISTINCTCOUNT ( DimFacility[CCN] )
Narratives How many 2567 / SOD preview rows are available for drill. COUNTROWS ( vw_SurveyNarrativeBoard )

Severity & Immediate Jeopardy

IJ is the call-now band. D-level volume will always dominate national charts; this board keeps band KPIs and IJ counts visible so D-tags cannot hide J/K/L.

MeasureOperator meaningCalculation
No Harm R12 Citations with S/S A–C (no actual harm / minimal potential). R12 count where ScopeSeverityCode IN { "A","B","C" }
Potential R12 Citations D–F — potential for more than minimal harm. Usually the bulk of volume. R12 count where code in D,E,F
Harm R12 Actual harm that is not IJ (G–I). R12 count where code in G,H,I
IJ R12 Immediate Jeopardy citations (J–L). Highest priority findings. R12 count where IsImmediateJeopardy = 1 (SQL: codes J/K/L).
IJ Share R12 What fraction of R12 findings are IJ — severity intensity, not just raw IJ count. IJ R12 ÷ Citations R12
Facilities w IJ R12 How many buildings had at least one IJ citation in R12 — portfolio IJ footprint. DISTINCTCOUNT ( CCN ) with IJ filter in R12.

Survey mix (standard / complaint / infection control)

CMS Provider Data Catalog flags these on the citation, not as a clean “survey type” dimension. One survey event can produce both standard- and complaint-flagged citations. The board treats flags honestly — no fake pie of survey types.

MeasureOperator meaningCalculation
Standard R12 Citations flagged standard deficiency = Y in R12. R12 count where StandardDeficiency = "Y"
Complaint R12 Citations flagged complaint deficiency = Y in R12. R12 count where ComplaintDeficiency = "Y"
IC R12 Infection-control inspection deficiency flags in R12 (often sparse nationally). R12 count where InfectionControlInspectionDeficiency = "Y"
Complaint Share R12 Share of R12 citations that carry the complaint flag — complaint pressure on the portfolio. Complaint R12 ÷ Citations R12

Correction, open-like & IDR / IIDR

CMS publishes multi-value Deficiency Corrected status language (plan of correction, no plan, past non-compliance, waiver, etc.). “Open-like” is an operator worklist definition — not a CMS field named Open.

IsOpenLike (SQL computed on each citation)

1 when DeficiencyCorrected is either:
  "Deficient, Provider has plan of correction"
  "Deficient, Provider has no plan of correction"
else 0
MeasureOperator meaningCalculation
Open R12 R12 citations still in open-like POC language — active worklist volume. R12 count where IsOpenLike = 1
Open 90d R12 Open-like citations whose survey date is more than 90 days before AsOf — aging risk. Open-like in R12 and SurveyDate < AsOf − 90
Median Days Fix Typical days from survey to correction date when both dates exist (all-history, not R12-only). MEDIANX of DATEDIFF ( SurveyDate, CorrectionDate, DAY ) on rows with both dates.
IDR Count Citations under Informal Dispute Resolution (Y flag). Count where CitationUnderIdr = "Y"
IIDR Count Citations under Independent Informal Dispute Resolution (Y flag). Count where CitationUnderIidr = "Y"

Internal risk weight

Each S/S letter has an internal integer weight on DimScopeSeverity (A=1 … L=56). Summing weight prioritizes portfolios with more severe letters — not CMS Five-Star and not the official health inspection score.

MeasureOperator meaningCalculation
Risk Weight R12 Sum of per-citation internal weights in the R12 window. Higher = more severity-weighted pressure. SUMX over R12 citations of LOOKUPVALUE ( RiskWeight by ScopeSeverityCode )
Risk Weight (ctx) Same sum in current filter context (charts by state, category, etc.). SUMX of risk weight on all citations in filter (no forced R12).
LetterBandInternal weight
A / BNo actual harm1
CNo actual harm2
DPotential for more than minimal harm4
EPotential for more than minimal harm6
FPotential for more than minimal harm8
GActual harm14
HActual harm18
IActual harm22
JImmediate Jeopardy40
KImmediate Jeopardy48
LImmediate Jeopardy56

Filter-context (ctx) measures

Charts and matrices that should respond to State / Facility slicers and cross-filters use (ctx) measures — plain counts in whatever filter the visual already has, without re-applying the R12 window inside the measure. Pair them with date or R12 visuals when you need both.

MeasureCalculation
Citations (ctx)COUNTROWS ( FactHealthCitation )
IJ (ctx)Count where IsImmediateJeopardy = 1
Open (ctx)Count where IsOpenLike = 1
Complaint (ctx)Count where ComplaintDeficiency = "Y"
Standard (ctx)Count where StandardDeficiency = "Y"
IC (ctx)Count where IC flag = Y
Harm (ctx)Count where S/S in G,H,I
Risk Weight (ctx)Sum of internal weights in context

Where measures appear by page

PagePrimary measures / fields
Risk overview Facilities R12, Citations R12, Survey Events R12, IJ R12, Open R12, Complaint R12, Standard R12, IJ Share R12; trajectory + state + band mix; scoreboard + IJ vs harm
Scope & severity No Harm / Potential / Harm / IJ R12, IJ Share, Risk Weight; letter matrix (All, R12, weight); band & letter charts; IJ by state
F-tags & categories Citations / IJ / IC / Complaint / Standard / Risk / Open R12; category & letter charts; category scoreboard; tag table
Survey mix Standard / Complaint / IC R12, Complaint Share, Cit per Survey, Survey Events; Std vs Cmp and IJ vs IC by state; state mix matrix
Correction & aging Open R12, Open 90d R12, Median Days Fix, IDR / IIDR counts; status & open-by-state charts; open-like worklist
Facilities Providers, Facilities R12, Citations / IJ / Open R12, Facilities w IJ, Narratives, Risk Weight; facility scorecard (ctx + published HI/Overall stars as context); ownership chart; 2567 preview

Scope & severity reference (CMS semantics)

Band labels and regulatory meaning come from the model dimension (aligned to CMS S/S grid language).

LetterBandRegulatory meaning (model)
ANo actual harmIsolated — no actual harm; potential for minimal harm
BNo actual harmPattern — no actual harm; potential for minimal harm
CNo actual harmWidespread — no actual harm; potential for minimal harm
DPotential for more than minimal harmIsolated — potential for more than minimal harm
EPotential for more than minimal harmPattern — potential for more than minimal harm
FPotential for more than minimal harmWidespread — potential for more than minimal harm
GActual harmIsolated — actual harm that is not IJ
HActual harmPattern — actual harm that is not IJ
IActual harmWidespread — actual harm that is not IJ
JImmediate JeopardyIsolated — IJ to resident health or safety
KImmediate JeopardyPattern — IJ to resident health or safety
LImmediate JeopardyWidespread — IJ to resident health or safety

Data notes

  • Primary fact: CMS health citations (Import). Dims: facility, scope/severity. Narrative board: SOD text preview view.
  • Standard / complaint / IC are citation flags from PDC — not inventable survey-type pies.
  • Published Overall / Health Inspection star columns on the facility scorecard are CMS context only.
  • This page is an internal/share-by-link measure guide and is intentionally omitted from the public docs index.