Scope & Severity – How Nursing Homes are Really Graded

Believe it or not, 90%+ of the staff members working in a nursing home have no idea of how the facility is assigned deficiencies (usually called tags or F-tags) or what the letter grade it receives actually means.  I am going to give you a quick and easy look at how deficiencies are cited per the scope & severity grid I included below.

NHP's Scope & Severity Grid


As you can see, we have a box with several columns and rows of letters.  The columns represent the scope or how many residents are affected.

The first column is Isolated – meaning the deficiency affects a very small number of residents or a limited number of staff are involved or that the situation occurred only occasionally.  A good rule of thumb for this Isolated column is 3.  If something affects 3 or less residents, it will usually be considered “Isolated.”

The next column is a Pattern.  This column is chosen when more than a few residents are affected, more than a limited number of staff are involved, or there are repeat occurences.  The rule of thumb for this column is 75%.  If a deficient practice affects more than 3 residents but less than 75% of the nursing home population, it generally will be considered a “Pattern.”

The last column is Widespread. This column is chosen when a problem affects a large number of residents or if there is systemic failure in a facility.  One of your systems is completely broken.  The rule of thumb here is if the deficient practice affects or has the potential to affect more than 75% of your population.


If the columns represent scope, then the rows have to represent the severity of the deficiency or basically how serious the issue is or what the potential for harm is.

Starting with the bottom row, Level 1 – Letters A, B, and C  – Deficiencies in this range are not serious.  They are not actual harm and they don’t have the potential to cause anything more than a minor negative impact on the residents.

The next row, Level 2 – D, E, and F – These tags are cited when there is noncompliance that is not actual harm but results in minimal discomfort to the resident or has the potential to cause harm.  These are very common citations in nursing home surveys.

The 3rd row, Level 3 – G, H, and I – These are no good.  They represent actual harm has occurred to a resident.  Keep in mind, even a bruise, skin tear, or making a resident upset can be considered actual harm.

The top row, Level 4 – J, K, and L – These are the worst tags you can get.  This is Immediate Jeopardy territory, or IJ’s for short.  Please keep in mind that IJ is just an abbreviation for immediate jeopardy and when you hear “IJ” it doesn’t represent I or J on the scope and severity grid.  It represents the classification of the row of  letters J, K, and L only.  So, a J is an IJ tag.  A K is an IJ tag. An L is an IJ tag.  Also, bear note that no actual harm has to occur to receive an IJ tag.

Immediate Jeopardy citations usually come with a nice big fine…and I mean big.  They can range from $3,050 up to $10,000 per day… yes, per day!  And, they can go back to the date of the incident.  If you had an elopement on April 1st and you had a survey on August 1st where they discover your door alarm still isn’t working correctly, you’ve just won 4 months of fines!

An item of note are the tags highlighted in dark blue – F, H, I, J, K – are considered “substandard” when cited in the areas of :

  • Resident behavior and facility practices
  • Quality of life
  • Quality of care

Now that we’ve run through the Scope & Severity, I’m going to show you how to put them together in order to predict what tag will be cited.

Let’s say that we have identified an avoidable stage 3 in-house acquired pressure ulcer on 1 resident in our facility.  The first question to ask is, Is it an immediate jeopardy; is their life or safety threatened?  Well, it could at some point affect that resident’s life if left untreated, but our scenario didn’t go that far.  We found it and are now treating it.  So, No – there is not an immediate jeopardy.

2nd question – Is there actual physical, mental, or emotional harm? Well, yes there is.  Our scenario stated that the pressure area was avoidable and it was acquired in the facility.  So, we know right off the bat, we’re getting an actual harm tag – G, H, or I.

Now, how many residents were affected?  We said 1, so it’s in the isolated column.  We just got ourselves an F-tag with a scope & severity of G – isolated, actual harm.  See how that works?

Now I’m going to give you a few scenarios so you can practice.  Feel free to share these with your team.  Answers are at the bottom.

Practice Scenarios:  What is the Scope & Severity of each?

  1. An Alzheimers resident is discovered outside the facility heading toward a busy street with no staff assistance.
  2. Two residents who have dementia were repeatedly observed during survey to have food spillage on their shirts and faces several hours after breakfast and lunch.
  3. The nurse performing woundcare treatments was observed not to wash their hands between residents on Wing A.  A review of patient records revealed that 3 residents on Wing A had developed wound infections in the past month.
  4. A resident was listed on admission 6 months ago as “active” and “vocal”.  The resident was restrained by the facility with no medical symptoms.  The resident is now “withdrawn and does not attend activities,” according to the medical record.  The resident stated on interview that she is very depressed.
  5. 35% of the facility’s 145 residents are in restraints.
  6. For 8 residents, activities are not being provided as directed by their care plans.  They are repeatedly observed sitting around the nurses station or in their rooms.  Two of the residents who can communicate say they are bored and there is nothing to do here.  The others cannot communicate.  They are often observed asleep in their wheelchairs.
  7. The Statement of Deficiencies was not posted nor was there any sign indicating where it was.  The surveyor inquired and was told it is in the business office and residents can ask for it.
  8. A dependent resident with Alzheimers was admitted on the first day of survey.  The surveyors observed this resident 3 times during the survey as being left in wet clothing for an hour or more after incidents of incontinence.  The resident was observed pulling at the crotch of her pants and crying on two occasions.  Examination of the resident’s skin revealed some redness.
  9. One resident developed an avoidable stage 4 pressure sore.
  10. A nursing home lobby sitting area had a terrible lingering odor after a family member who did not bathe regularly had visited.
  11. A resident who had a recent upper respiratory infection was found to have a thru-the-wall air conditioner with a dirty filter.
  12. A CNA shut the resident’s door but failed to pull the privacy curtain when giving incontinence care.  She then told visitors who knocked on the door to “Come in” without covering the exposed resident.  The surveyor was in the room the whole time.
  13. Eight residents came to the surveyor to complain that they had all been in the lounge watching the World Series.  It went into overtime and was still going on at 11 p.m.  All eight residents were removed from the lounge and put to bed against their will since 3rd shift insists that all residents be already in bed when they begin working.  The residents were furious about missing the end of the game.  None had a personal tv in their room.  ***Note:  This one is a little tricky!



  1. You have an immediate jeopardy J-tag.
  2. D – potential dignity issue.
  3. G-tag, actual harm for 3 residents.  Note that there doesn’t have to be rock-solid proof that the infections came from the deficient practice.
  4. G-tag, actual harm.  Was restrained with no medical symptoms.  Psychological harm.
  5. This is not necessarily a deficient practice.  More information is needed before this can be cited.
  6. E-tag, potential for harm.
  7. C-tag, it affects all the residents.
  8. G-tag, actual harm – the resident is crying.
  9. G-tag, actual harm.  The pressure sore was avoidable.
  10. Believe it or not, I have seen this tag cited before at an F level.
  11. I actually received this tag at a G-level before.  Obviously, there was no proof the URI actually was caused by the dusty ac filter and we had all the filters on a PM cleaning schedule, which I had documented proof of.  I asked for an Informal Dispute Resolution (IDR) and got this tag deleted – maintaining a 100% IDR success rate.
  12. D-tag, dignity.
  13. At first, you’d think that you had an H-tag since 8 residents were involved.  However, you’ll be receiving an I-tag due to the fact that 3rd shift insists that ALL residents are in bed at 11 p.m.

Keep in mind that these scenarios are just examples.  There are many factors that could change the scope & severity cited and each survey team is different.  I hope you enjoyed these examples.  I use them to train staff and it provides an interactive setting to remind staff how easy it is to receive citations.  Good luck!

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2 Responses to “Scope & Severity – How Nursing Homes are Really Graded”

  • Edna Yonkers on

    Need a chart regarding the points assigned to the scope and severity as it relates to the five star rating.

  • Mark on

    Hi, Edna. I’ll see what I can do for you.


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