Sens. Elizabeth Warren and Mazie Hirono have asked CMS to justify its Risk-Based Survey, a shortened inspection that sends two surveyors instead of four to qualifying nursing homes of up to 174 residents, and they want answers by November 9. Rehinged’s proxy for the qualifying pool covers 4,688 scored facilities, nearly a third of the market, while another 990 have gone more than two years without a health inspection. Separately, Ensign Group raised its 2026 outlook on 84.1% same-facility occupancy, a level the average scored facility, at 80.4%, has not reached.
Why it matters for vendors: If CMS narrows or suspends the lighter survey, the 4,688 facilities now expecting it would face full inspections, and Texas (387), California (379) and Ohio (302) hold the most of them. Survey-readiness and infection-control vendors can use the senators’ letter as the reason operators should not relax. On the census side, 1,904 facilities rated one or two stars are running below 75% occupancy, 396 of them in Texas, a different buyer profile from the staffing-constrained facilities that dominated recent editions.
RegulatoryQuality & Ratings
Two Senators Challenge CMS’s Risk-Based Survey, Questioning Whether a Shorter Inspection Protects Residents
What happened
Sens. Elizabeth Warren (D-Mass.) and Mazie Hirono (D-Hawaii) sent a letter to CMS Administrator Mehmet Oz challenging the Risk-Based Survey. For qualifying facilities of up to 174 residents, CMS sends two surveyors instead of four and starts with a sample of six residents; infection control is the only task the abbreviated survey makes mandatory. The senators say the eligibility criteria ignore finances and ownership structure despite research linking private equity ownership to worse outcomes, and they ask whether the shorter process meets federal statutory requirements.
The letter leans on figures from the National Consumer Voice for Quality Long-Term Care: an estimated 114,300 residents could be affected, 27 eligible homes received a resident-abuse designation since September 2025, 478 had not had a standard survey in over a year, and 73 had Medicare or Medicaid payment denials in the past four years. About half of the newly eligible facilities would not have qualified a year earlier. The senators also worry that the “trophy” icon on Nursing Home Care Compare will lead families to assume designated homes provide superior care. CMS has until November 9 to answer.
Why it matters
A shorter survey lowers the odds of citations at qualifying homes, and operators may be tempted to cut readiness spending as a result. The letter signals that the program is politically exposed. If CMS tightens eligibility, adds suspension triggers or reworks the trophy icon, facilities that planned around two-surveyor visits could face full inspections with little notice, and that favors vendors who help operators stay survey-ready year-round.
CMS has not published a facility-level eligibility list that Rehinged can match, so this analysis uses a proxy: facilities with a health inspection rating of four or five stars, no resident-abuse icon, no Special Focus Facility status or candidacy, and 174 beds or fewer. 4,688 scored facilities (31.9% of the market) meet that test. They average 4.50 stars overall and 83 beds, which makes them small, well-rated buildings that have the most to lose if the shortened visit goes away.
4,688
likely lighter-touch survey candidates (31.9% of scored SNFs)
154
of those also score 70 or higher on infection-prevention need
990
facilities whose last health inspection was over two years ago
Likely lighter-touch survey candidates, by state
The compound picture cuts two ways. Because infection control is the one mandatory element of the shortened survey, the 154 candidates that also score 70 or higher on infection-prevention need are where that single check lands on the weakest footing; California has the most (20), followed by Illinois (12), Massachusetts (10) and Michigan (10). At the other end, 990 facilities have not had a health inspection in more than two years, and they average only 2.90 stars. Alabama (193), Virginia (175) and New York (111) hold the most, and 65 of them also score 70 or higher on infection-prevention or patient-safety need, with an average rating of 1.98 stars. Vendors selling survey-readiness, mock-survey or infection-control programs should work Texas, California and Ohio for the candidates and Alabama and Virginia for the overdue facilities, where a long-delayed visit may be coming.
Facilities with a health inspection more than two years old, by state
Watch for: CMS’s response due November 9, any change to eligibility or suspension criteria, and whether the Care Compare trophy icon is reworked. A related note from McKnight’s: CMS’s nursing home policy chief said Monday the agency would support more past-noncompliance citations, which tend to be less severe than citations for ongoing problems.
Market TrendsM&A / Ownership
Ensign Raises Its 2026 Outlook as Same-Facility Occupancy Reaches 84.1%
What happened
Ensign Group reported third-quarter adjusted earnings of $2.03 per share against a $1.97 estimate and raised full-year 2026 guidance to $7.94 to $8.02 per share. Revenue rose 14.5% to $1.48 billion, short of the $1.51 billion analysts expected. GAAP net income grew 24.4% to $104.3 million, same-facility occupancy reached 84.1%, and the company added 22 operations, including its first in Florida. Shares rose about 8% in morning trading.
Why it matters
Ensign is one of the largest publicly traded skilled nursing operators, and a raised outlook with continued acquisitions means its purchasing and clinical-program decisions will keep shaping what peers copy. Its occupancy also sets a benchmark: across the 14,620 scored facilities with a valid occupancy reading, the average is 80.4%, so Ensign’s same-facility figure sits nearly four points above the market.
The gap runs the other way for a meaningful group of operators. 1,904 scored facilities (13.0% of the market) are both below 75% occupancy and rated one or two stars overall. They average 1.43 stars and 123 beds, so they are large buildings with empty capacity and weak ratings, the opposite of the profile behind Ensign’s results. Florida, where Ensign is now entering, is a high-census market: its scored facilities average 88.2% occupancy, nearly eight points above the national figure.
1,904
facilities below 75% occupancy and rated 1 or 2 stars (13.0% of scored SNFs)
80.4%
average occupancy across scored facilities, against Ensign’s 84.1%
9
of those 1,904 also score 70 or higher on staffing need
Under-filled, low-rated facilities, by state
Only 9 of the 1,904 also score 70 or higher on staffing need, which tells us their problem is census and quality rather than hiring. That makes them poor targets for workforce tools and better targets for referral-development, admissions-conversion, discharge-planning and quality-improvement vendors. Texas holds 396 of them, followed by Illinois (171) and Missouri (142). Vendors selling census-building or quality-turnaround services should start in those three states, and those serving growth operators should track where Ensign’s Florida acquisitions land.
Watch for: Further Florida acquisitions from Ensign, whether revenue growth catches up with earnings in the fourth quarter, and whether peers with similar occupancy raise guidance as well. Note that Rehinged’s occupancy average excludes 123 facilities whose reported ratios exceed 100%.