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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CIA A. BUILDING
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How to fill out a nursing home survey report:

01
Begin by carefully reading the instructions provided with the survey report. Familiarize yourself with the format, sections, and requirements.
02
Collect all necessary information before starting the report. This may include patient records, staff information, facility policies, and any incident reports.
03
Start by providing general information about the nursing home, such as its name, address, and contact details.
04
Proceed to the patient care section. Evaluate and record the quality of care provided, including medication administration, treatment plans, monitoring of vital signs, and assistance with daily living activities.
05
Assess the facility's cleanliness and maintenance. Include observations on the overall cleanliness of patient rooms, common areas, and restrooms. Check for any potential safety hazards or maintenance issues.
06
Evaluate the staff performance and competence. Assess the adequacy of staffing levels, consistency of assignments, and their qualifications. Document any incidents of possible neglect or abuse.
07
Review the administrative procedures and policies. Assess if there are proper protocols in place for handling complaints from residents or their families, as well as documentation of incidents, emergency plans, and procedures for admitting new patients.
08
Inquire about the quality of life of residents. Is there a wide range of activities and social events available? Are residents given opportunities for exercise, engagement, and personal fulfillment?
09
Lastly, provide an overall evaluation and summary of the nursing home's performance. Highlight any areas of concern or areas where improvements could be made.

Who needs a nursing home survey report?

01
The management of the nursing home needs a survey report to assess the facility's compliance with regulations and standards, identify areas for improvement, and ensure the well-being of residents.
02
Regulatory agencies, such as state health departments or accreditation organizations, require nursing home survey reports to monitor and enforce compliance with regulations and guidelines.
03
Insurance companies and third-party payers may also request survey reports to determine the quality of care provided by the nursing home before entering into contracts or making reimbursement decisions.
04
Potential residents and their families may review survey reports to make informed decisions about choosing a nursing home. The report can provide insight into the quality of care, safety, and overall reputation of the facility.
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Nursing home survey report is a detailed documentation of the quality of care provided at a nursing home, including findings from inspections, ratings, and any deficiencies found.
Nursing home administrators are typically required to file the nursing home survey report.
The nursing home survey report is typically filled out by documenting observations, inspections, and ratings based on the care provided at the nursing home.
The purpose of the nursing home survey report is to ensure that nursing homes are providing quality care to their residents and meeting regulatory standards.
The nursing home survey report must include details of inspections, findings, ratings, deficiencies, and corrective actions taken.
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