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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:5 27/2015 FORM APPROVED OMB NO. 09380391 (X3) DATE SURVEY
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How to fill out a nursing home survey report:

01
Begin by carefully reviewing the instructions provided. Take the time to understand the purpose and format of the survey report.
02
Collect all the necessary information before starting. This includes details about the nursing home, its staff, residents, services offered, and any specific incidents or issues that need to be addressed in the report.
03
Use clear and concise language when documenting your observations. Be objective and avoid personal opinions or biases.
04
Organize the report accurately by following the designated sections or categories. Include all required information and complete each section thoroughly.
05
Provide specific details and examples to support your findings. Use dates, times, names, and any other relevant information to help substantiate your observations or concerns.
06
If there are any deficiencies or areas for improvement, clearly describe them and suggest possible solutions.
07
Double-check your report for any errors or omissions before submitting it. Ensure that all information is accurate, and the report is written professionally.
08
After completing the report, submit it to the appropriate authority or department as instructed.

Who needs a nursing home survey report:

01
Government regulatory bodies: Nursing home survey reports are often required by government agencies responsible for overseeing and regulating nursing homes to ensure their compliance with health and safety standards.
02
Nursing home administrators and management: These reports provide valuable feedback to the administrators and management team, helping them identify areas that require improvement and take appropriate actions.
03
Nursing home staff: Survey reports can be utilized as training tools for staff members, raising awareness about deficiencies and the importance of providing quality care.
04
Residents and their families: Survey reports can be beneficial to residents and their families, as they provide insights into the quality of care provided, potential risks, and any areas of concern that need to be addressed.
05
Advocacy groups and watchdog organizations: Such reports can be used by advocacy groups and watchdog organizations to monitor and advocate for better standards of care in nursing homes.
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The nursing home survey report is a document that evaluates the quality of care provided by nursing homes.
Nursing homes are required to file the survey report.
The survey report can be filled out by providing detailed information about the care practices and policies in place at the nursing home.
The purpose of the nursing home survey report is to assess and monitor the quality of care provided to residents.
The report must include information on staffing levels, resident health outcomes, and compliance with regulatory standards.
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