Special Focus Facilities


The Special Focus Facility or SFF designation is one that all Nursing Homes hope to avoid.  Facilities with a history of major deficiencies on their annual Health Inspections/Surveys put themselves at risk for inclusion in the program, which includes increased oversight, more frequent surveys, and a requirement to improve or risk losing their Medicare/Medicaid certification.

SFF Candidacy

Facilities qualify for inclusion in a list of SFF Candidates based on their performance on their annual Surveys.

For each shortcoming on the inspection, the facility is issued a deficiency.  Points are assigned based on the scope and severity of the deficiency.  The points from the past 3 survey cycles are totaled, weighted, and compared against all the other homes in a given state. This point total – the Weighted Survey Score – is used to determine the facility’s Survey Star Rating.


The facilities with the highest Weighted Survey Scores become SFF Candidates.  How many facilities qualify is based on the number of slots available, which varies by state:



Some states have more slots, relative to the total number of facilities, than others.  As you can see from the map below, several western states have a relatively low number of facilities, but there are still 5 SFF Candidate slots.  So poor-performing homes in these states run an higher risk of being included in the program.  



Four states and territories (Alaska, Puerto Rico, Guam and Washington, D.C.) have so few facilities that there are no SFF Candidate slots.  This means that there’s no possibility of these homes ever being included in the SFF program at all!


SFF Impacts & Insights

For facility operators, SFF status can represent a huge burden.  In addition to the increased oversight, referrals can quickly dry up and financing can be more difficult to find.  The department of Housing and Urban Development (HUD) now includes SFF status as a major part of its considerations for underwriting section 232 loans.  Also, Star Ratings for SFFs are suspended until graduation from the program, making it difficult to assess other key areas of performance in the home.

For investors, SFF status can either represent a liability or an opportunity, depending on the track record of the operator.  Either way, it’s important to understand where a facility stands when making decisions in underwriting.

CMS publishes a list that includes facilities in the SFF program divided by status, including SFF Candidates, but it can sometimes be difficult to determine how close a poor-performing facility many be to SFF status.  With StarPRO’s tools, it’s easy to quickly see how a facility stacks up, either alone, or as a part of a portfolio.

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SFF Selection, Graduation & Termination

Being an SFF Candidate carries no specific penalties, but the status is published on Nursing Home Compare and the facility is eligible to be selected as a Special Focus Facility at any time.  When a facility in the SFF program graduates or is terminated, the State Survey Agency looks at the list of SFF Candidates and selects a new facility to be included.  There’s generally one SFF per 5 SFF Candidate slots, so a state with 30 slots would have 6 SFFs at any given time.

Once a facility is selected as an SFF, they’re immediately inspected and will have surveys conducted at least every six months.  Facilities must show constant improvement on all subsequent surveys or face enforcement actions including fines, denials of payment, and/or temporary management.  With a few exceptions, facilities can graduate from the SFF program by having two consecutive “passing” surveys (those with no deficiencies cited at a scope and severity of “F” or greater).

Facilities with three “failing” surveys in a row are given one “last chance” survey.  Based on the results of this survey, CMS and the State Survey Agency will determine whether or not to terminate the facility’s certification.  

For more details on selection, graduation and termination, see the CMS documentation here.

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