What Is a Special Focus Facility? What Happens When a Nursing Home Is Put on the CMS SFF List

What Is a CMS Special Focus Facility (SFF)?

A Special Focus Facility (SFF) is a nursing home with a long history of serious quality and safety problems that CMS has placed under heightened oversight in a federal program. CMS describes SFF nursing homes as having about twice the average number of deficiencies, more serious problems, and a pattern lasting about three years.

Most nursing homes average six to seven deficiencies per standard health inspection, according to CMS. CMS identifies SFFs by three traits:

• More problems: about twice the average number of deficiencies
• More serious problems, including harm or injury to residents
• A pattern of serious problems persisting over about three years

CMS calls this "yo-yo" compliance: a facility fixes enough to pass one inspection, then the problems resurface at the next. Each citation behind that pattern is an F-tag on the facility's CMS-2567.

What is the Special Focus Facility program?

The Special Focus Facility program is a federal oversight program, required by sections 1819(f)(8) and 1919(f)(10) of the Social Security Act, that inspects the persistently poorest-performing nursing homes in each state at least once every six months and applies progressively stronger enforcement until they improve.

CMS runs the SFF program with state survey agencies under policy memo QSO-23-01-NH, most recently revised January 28, 2026. CMS expects selected facilities to make and sustain improvements quickly enough to graduate.

How Does a Nursing Home Enter the SFF Program and Get on the List?

A nursing home gets on the SFF list by ranking among the worst-scoring facilities in its state on CMS's health inspection scoring, which makes it an SFF candidate, and then being selected by the state survey agency, with CMS approval, when one of the state's SFF slots opens.

1. CMS converts the last two standard health survey cycles and three years of complaint surveys into points, using the Five-Star Health Inspection method.
2. More deficiencies, and higher scope and severity, mean more points.
3. The facilities with the most points in each state become SFF candidates.
4. When a slot opens, the state survey agency recommends one candidate within 21 calendar days, and the CMS location approves it.
5. Since January 2026, CMS recommends states favor the candidate with the higher prevalence of resident falls when compliance histories are similar.

States may also weigh earlier complaint findings or enforcement actions. To see whether your own pattern resembles a candidate's, try the private SFF Risk Self-Check. The scoring itself is explained in how the Five-Star rating works.

SFF vs. SFF Candidate: What Is the Special Focus Facility Candidate List?

The Special Focus Facility candidate list is CMS's monthly list of nursing homes that qualify to be selected as an SFF but have not been chosen, with five candidates for every SFF slot. An SFF candidate is not yet in the program; an active SFF has been selected and is under six-month surveys and immediate remedies.

SFF candidate status is the clearest early warning a nursing home gets. Every open slot is filled from the CMS Special Focus Facility candidate list, so the work that keeps a candidate from being selected is the same work an active SFF needs to graduate.

How Many Special Focus Facilities Are There?

There are 88 Special Focus Facility slots nationwide, a number CMS sets by the funding it receives for twice-yearly surveys, with between one and six slots per state. CMS's September 30, 2026 posting listed 87 current SFFs and 440 SFF candidates.

Sources: QSO-23-01-NH, the HHS OIG data snapshot, and the September 30, 2026 CMS posting. HHS OIG notes SFFs are less than one-tenth of 1 percent of nursing homes at any time.

What Happens When You Are Put on the CMS Special Focus Facility List?

When a nursing home is put on the CMS Special Focus Facility list, it receives a selection notice, loses its Care Compare star ratings, and moves to a standard health survey at least every six months, with immediate, escalating remedies for serious citations until it graduates or is terminated.

Heightened inspections and oversight

A Special Focus Facility is surveyed by its state survey agency at least once every six months, about twice as often as other nursing homes, and CMS tells states to keep the timing as unpredictable as possible. Enforcement is progressive: each repeat serious citation must bring a more severe remedy.

Public disclosures and reputation

SFF status is public. CMS names every current SFF in its monthly posting on cms.gov, and Care Compare shows an SFF warning icon in place of star ratings. CMS also lists graduates for three years after they leave the program.

The path to graduation or termination

An SFF leaves the program by graduating or by being terminated from Medicare and Medicaid. CMS considers discretionary termination for an SFF cited for Immediate Jeopardy on any two surveys, and monitors graduates for three years afterward.

The full sequence, step by step

The Special Focus Facility process has 10 steps, from appearing on the SFF candidate list to graduating or being terminated from Medicare and Medicaid, as set out in CMS memo QSO-23-01-NH (revised January 28, 2026). The steps below follow that memo in order.

SFF remedies can include civil money penalties, denial of payment for new admissions, and directed plans of correction. See CMS enforcement actions explained for how each works.

SFF Consequences at a Glance

The main consequences of Special Focus Facility status are twice-as-frequent surveys, immediate and escalating remedies, removal of star ratings, monthly public listing on cms.gov, and termination review after Immediate Jeopardy on any two surveys.

The federal deadlines for every nursing home still apply to an SFF: denial of payment for new admissions if not back in substantial compliance within three months, and termination at six months. An Immediate Jeopardy citation carries extra weight for an SFF.

What Does SFF Status Do to a Nursing Home's Star Ratings?

SFF status removes a nursing home's star ratings: under CMS's Five-Star Technical Users' Guide (July 2026), current Special Focus Facility participants are not assigned an overall rating or any domain rating, and Care Compare shows a yellow warning sign instead.

The other domains display "Not Available." The SFF designation comes off Care Compare in the month after a facility graduates. See how Care Compare works and how to improve a Five-Star rating.

How Does a Nursing Home Leave the SFF Program? Graduation or Termination

SFF status ends in one of two ways: the Special Focus Facility graduates by meeting CMS's criteria on two consecutive standard health surveys, or it leaves Medicare and Medicaid through termination or closure. Of 645 SFFs from 2013 to 2022, HHS OIG counted 495 graduates and 71 terminations or closures.

Each qualifying survey must have 12 or fewer deficiencies, all at scope and severity E or below. Our step-by-step SFF graduation guide covers what disqualifies a facility, a seven-step plan, and realistic timelines.

Should Families Avoid a Special Focus Facility? How to Check a Nursing Home

CMS does not tell families to avoid Special Focus Facilities, but its posting advises extra diligence before admission: check the home on Care Compare, visit, ask what the staff are doing to improve, and contact the state survey agency and the long-term care ombudsman. CMS adds that an SFF is inspected twice as often as other nursing homes.

What is a special focus facility nursing home?

A special focus facility nursing home is a nursing home currently in CMS's Special Focus Facility program because of a long history of serious quality and safety problems. It is under closer federal monitoring than other homes and shows an SFF warning icon, not star ratings, on Care Compare.

How to check whether a nursing home is an SFF

Checking whether a nursing home is a Special Focus Facility takes four steps using CMS sources: Care Compare, the monthly CMS SFF posting, PoC360's state tool and the state survey agency. A current SFF shows a warning icon on Care Compare instead of star ratings.

1. Search the home on Medicare Care Compare; a current SFF shows a warning icon in place of the overall rating.
2. Check the latest CMS SFF posting: Table A lists current SFFs, Table B graduates from the past three years, and Table D candidates.
3. Or use our free Special Focus Facility List by State to see current SFFs and candidates for any state.
4. Call the state survey agency (contact details are on Care Compare) and the local long-term care ombudsman.

What should families look at once they find an SFF?

• Staffing, quality measures and inspection results on Care Compare
• The latest survey result in Table A of the CMS posting: “Met” means the home met the graduation criteria on its latest survey, “Not Met” means it did not
• Months in the program: CMS says homes past 18–24 months are closer to graduating or leaving Medicare and Medicaid
• Whether the home appears in Table B: graduates stay listed for three years, but CMS notes graduation does not mean there are no quality problems
• What staff say they are doing to improve care when you visit

Facilities that graduate sustain improvement across two consecutive standard surveys. HHS OIG found 64 percent of 2013–2022 graduates later received a serious deficiency within three years, so a graduate's recent survey results matter as much as its graduation. Our Care Compare guideexplains how to read the rest of a home's profile.

Falls and the SFF Program: What Surveyors Check

Falls matter to the Special Focus Facility program in two ways. Since January 28, 2026, CMS recommends states favor SFF candidates with a higher prevalence of resident falls, and CMS's surveyor guidance cites a fall caused by a lack of required supervision at F689, "Free of Accident Hazards/Supervision/Devices."

How common are F689 citations?

F689 was cited 5,232 times on surveys dated August 1, 2025 through July 31, 2026, according to CMS's Health Deficiencies dataset, about 5.7 percent of the 91,201 citations in that period.

Source: CMS Provider Data Catalog, Health Deficiencies, August 2026 refresh, queried October 7, 2026. F689 covers all accident hazards and supervision, not only falls, so this is the nearest single tag, not a falls-only count. Counts change with each monthly refresh.

Immediate Jeopardy carries extra weight for an SFF, because IJ on any two surveys puts an SFF up for termination review. See Immediate Jeopardy citations and the most-cited F-tags.

What do surveyors look for on falls?

CMS's State Operations Manual, Appendix PP, expects a facility to run a systematic process for accident prevention rather than react to each fall. The guidance for F689 points to these elements:

• Identifying and evaluating hazards and each resident's fall risk factors, including medications, mobility, cognition and environment
• An individualized care plan built from the resident assessment, with supervision and assistive devices matched to risk
• After a fall: check for injury, work out what caused it and what the resident was trying to do, address the risk factors, and revise the care plan
• Monitoring whether interventions work and changing them when they don't

The MDS defines a fall as unintentionally coming to rest on the ground, floor or other lower level, and CMS guidance notes that a fall without injury is still a fall. States see falls information on the monthly SFF candidate list, and providers can see their own falls data in the iQIES MDS 3.0 Facility-Level Quality Measure Report. See how to track quality measures and the daily compliance checklist.

What Changed in the SFF Program in January 2026?

On January 28, 2026, CMS revised QSO-23-01-NH to score SFF candidates on two standard survey cycles instead of three and to emphasize resident falls in selection. The graduation criteria, termination criteria and three-year monitoring period did not change; we checked the revised memo against the September 2023 version line by line.

January 28, 2026: candidate scoring drops to two survey cycles

Since January 28, 2026, SFF candidates are identified from the last two standard health survey cycles plus three years of complaint surveys, down from three standard cycles. That matches the July 2025 change to the Five-Star Health Inspection rating.

January 28, 2026: falls replace staffing as the selection focus

Under the January 2026 SFF memo, states choosing between candidates with similar compliance histories should favor the one with the higher prevalence of resident falls. The 2023 version pointed to lower staffing. Falls data appears on the monthly candidate list and in the iQIES MDS 3.0 Facility-Level QM Report.

January 28, 2026: survey frequency spelled out

The January 2026 SFF memo specifies a standard health survey at least once every six months (no less than twice a year) and Life Safety Code and Emergency Preparedness surveys at least annually.

January 28, 2026: smaller process updates

The January 28, 2026 revision of QSO-23-01-NH also made five smaller process changes that do not alter the SFF graduation or termination criteria: list timing, iQIES access, QIN-QIO naming, a renamed F884 tag and the location of the monthly postings.

• States may select from the most recent candidate list if a new monthly list is not yet out
• Candidates retrieve their Five-Star preview through iQIES
• QIO references updated to QIN-QIO (Quality Innovation Network-Quality Improvement Organization)
• Graduation carve-out tag F884 renamed "COVID-19 and Respiratory Illness Reporting to CDC"
• SFF postings now live on the CMS Nursing Homes page

Earlier: October 2022 overhaul and October 2025 OIG reports

CMS's October 2022 overhaul (technical corrections September 2023) set today's graduation test, the IJ-on-two-surveys termination criterion and three-year post-graduation monitoring. In October 2025, HHS OIG found 64 percent of 2013–2022 graduates had a serious deficiency within three years.

For other changes this year, see CMS regulatory changes in 2026.

Common Misconceptions About Special Focus Facilities

The most common misconceptions about Special Focus Facilities are that every state has about two, that SFFs are capped at three stars, and that avoiding Immediate Jeopardy is enough to graduate. Each is wrong under current CMS guidance.

• Myth: there are about two SFFs in every state. Fact: there are 88 slots, with one to six per state.
• Myth: SFFs are capped at 3 stars. Fact: current SFFs get no star ratings at all; Care Compare shows a warning icon.
• Myth: avoiding Immediate Jeopardy is enough to graduate. Fact: graduation needs 12 or fewer deficiencies, all at E or below, on two consecutive standard surveys.
• Myth: one bad survey puts a facility on the list. Fact: scoring uses two standard survey cycles and three years of complaint surveys.
• Myth: the January 2026 revision added new termination rules. Fact: the IJ-on-two-surveys criterion dates from October 2022; 2026 changed candidate scoring and selection.
• Myth: graduation means the problems are fixed. Fact: CMS says graduation doesn't mean there are no quality problems, and HHS OIG found 64% of graduates had a serious deficiency within three years.

What Are a Facility's Options After SFF Selection?

A nursing home selected as a Special Focus Facility can run an in-house turnaround, bring in an outside consultant or the QIN-QIO, or add compliance software, and CMS counts consultant help and QIN-QIO engagement as good-faith effort. Most SFFs combine approaches.

In-house work costs least but relies on the systems that produced the SFF pattern. A consultant adds objectivity at higher cost. Software keeps ownership and evidence running through staff turnover but doesn't change care on its own. The graduation guide compares these options in detail.

First Steps After SFF Selection: Checklist

A newly selected Special Focus Facility should record its enrollment date, send accountable-party details to the state within five business days, and start correcting anything at scope and severity F or above before the first six-month survey.

For the corrections themselves, see how to write a Plan of Correction.

What Is the CMS List of Special Focus Facilities, and Where Do You Find It?

The CMS Special Focus Facility list is a monthly PDF, titled "SFF Posting with Candidate List," that names every current SFF, recent graduate and SFF candidate. CMS publishes it on its Nursing Homes pageand updates it monthly, so check the "Updated" date on the latest file.

1. Open the CMS Nursing Homes page. Go to the CMS Nursing Homes page on cms.gov and scroll to "Special Focus Facility Initiative and List."
2. Download the latest SFF Posting with Candidate List. Open the most recent monthly PDF and check its "Updated" date. CMS also posts an SFF List Archive ZIP file beside it.
3. Find the facility in the right table. Search by name or CMS Certification Number. Table A lists current SFFs, Table B graduates from the past three years, Table C facilities no longer in Medicare and Medicaid, and Table D SFF candidates.
4. Confirm on Care Compare. Look the facility up on Medicare Care Compare. A current SFF shows a warning icon instead of an overall star rating.
5. Or filter by state in one step. Use PoC360's free Special Focus Facility List by State tool, which pulls the same CMS data live and filters it by state.

Where are past monthly SFF lists?

Past CMS Special Focus Facility lists, including earlier 2025 and 2026 monthly postings, remain available through the SFF List Archive ZIP file on the CMS Nursing Homes page. Individual monthly PDFs also stay online at their original cms.gov addresses.

Official sources

• CMS Nursing Homes page: Special Focus Facility Initiative and List
• QSO-23-01-NH, Revisions to the SFF Program (revised January 28, 2026, PDF)
• Medicare Care Compare
• HHS OIG report on the SFF program (October 2025)