# Deficiency

> A deficiency is a failure to meet a Medicare or Medicaid rule. A surveyor, or inspector, lists it on Form CMS-2567 and nursing homes get a score.

Source: https://incidentkit.ai/glossary/deficiency · Updated Oct 5, 2026

Also known as: survey deficiency, citation, survey finding

## What counts

Under 42 CFR 488.301, a nursing home deficiency is a failure to meet a rule in the Act or in 42 CFR Part 483, Subpart B.

Noncompliance is a failure big enough that the home is not in substantial compliance. Substantial compliance means any gaps pose no more than a potential for minimal harm.

Other providers have standard-level and condition-level gaps. A condition is a broad rule. Standards are the details under it. A gap reaches condition level based on how well the provider meets the standards (42 CFR 488.26).

## How it is scored

| Severity | Isolated | Pattern | Widespread |
| --- | --- | --- | --- |
| Immediate jeopardy (level 4) | J | K | L |
| Actual harm, not immediate jeopardy (level 3) | G | H | I |
| No actual harm, potential for more than minimal harm (level 2) | D | E | F |
| No actual harm, potential for minimal harm (level 1) | A | B | C |

Level A is not listed on Form CMS-2567 and needs no [plan of correction](https://incidentkit.ai/glossary/plan-of-correction). All other levels need one. Example: a resident falls and breaks a bone because a care-plan step was missed. In one resident, that scores G.

Mix-up: a deficiency is not automatically a fine. The remedy depends on the score and history.

## Frequently asked questions

### What is the difference between a deficiency and noncompliance?

Noncompliance (42 CFR 488.301) is a deficiency that keeps a nursing home from substantial compliance. A level A deficiency can leave a home in substantial compliance.

### What is a standard-level versus a condition-level deficiency?

Conditions are broad rules. Standards are the details beneath. With only standard-level gaps, a provider may keep taking part if it files an acceptable plan of correction.

### Does every deficiency require a plan of correction?

Almost. Nursing homes with findings above scope and severity level A must file one. Other providers with standard-level findings must file one to keep taking part.

## Sources

- [42 CFR 488.301: Definitions (nursing home survey and enforcement)](https://www.ecfr.gov/current/title-42/section-488.301)
- [42 CFR 488.26: Determining compliance](https://www.ecfr.gov/current/title-42/section-488.26)
- [42 CFR 488.28: Providers or suppliers, other than SNFs, NFs, HHAs and hospices, with deficiencies](https://www.ecfr.gov/current/title-42/section-488.28)
- [CMS State Operations Manual, Chapter 7: Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities](https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107c07pdf.pdf)
- [CMS State Operations Manual, Chapter 2: The Certification Process](https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107c02.pdf)

## Related terms

- [Immediate jeopardy](https://incidentkit.ai/glossary/immediate-jeopardy)
- [CMS-2567](https://incidentkit.ai/glossary/cms-2567)
- [Plan of correction](https://incidentkit.ai/glossary/plan-of-correction)
- [F-tag](https://incidentkit.ai/glossary/f-tag)
- [Conditions for coverage](https://incidentkit.ai/glossary/conditions-for-coverage)

## Related

- [Plan of correction (CMS-2567): elements and 10-day deadline](https://incidentkit.ai/compliance/survey-readiness/plan-of-correction)
- [Nursing home recertification survey: process and prep](https://incidentkit.ai/compliance/survey-readiness/snf-recertification-survey)
- [ASC survey readiness: what surveyors ask for and check](https://incidentkit.ai/compliance/survey-readiness/asc-survey-readiness)
- [What to put in a plan of correction (CMS-2567)](https://incidentkit.ai/blog/what-to-put-in-a-plan-of-correction)
- [QAPI, survey and OSHA compliance packets](https://incidentkit.ai/product/compliance-packets)