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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:11 24/2014 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 reading all instructions provided with the survey report. This will give you a clear understanding of what information is required and how to properly document it.
02
Take notes during your observation of the nursing home facility. Pay attention to various aspects such as the cleanliness of the environment, the behavior of staff members, the overall safety measures in place, and the quality of care provided to residents.
03
In the survey report, provide detailed descriptions of any concerns or issues you have identified during your visit. Be specific and include relevant dates, times, and locations for each observation you report.
04
When documenting any incidents or grievances, ensure that you include accurate and concise information. Describe the situation objectively and avoid adding personal opinions or biases.
05
Fill in all required sections of the survey report, including demographic details about the nursing home facility, its staff, and the residents. Provide accurate information to the best of your knowledge and avoid making assumptions.
06
Utilize any additional resources or tools provided by the survey report to support your findings. This may include checklists, rating scales, or specific assessment criteria. Be sure to complete these sections thoroughly and accurately.

Who needs a nursing home survey report?

01
State regulatory authorities: Nursing home survey reports are typically required by state regulatory authorities to ensure that nursing homes are operating in compliance with health and safety regulations. These reports help authorities identify any deficiencies or issues that need to be addressed.
02
Nursing home administrators: Survey reports provide valuable feedback to nursing home administrators on areas requiring improvement. Administrators can use the report findings to implement changes and enhance the overall quality of care provided to residents.
03
Potential residents and their families: Nursing home survey reports can serve as a valuable resource for individuals seeking a nursing home facility. Families can review these reports to assess the quality of care, safety measures, and overall environment of potential nursing homes before making a decision.
04
Insurance companies and healthcare organizations: Nursing home survey reports might be required by insurance companies or healthcare organizations that need to assess the quality of care provided before establishing business agreements with a particular facility. These reports help ensure that the facility meets certain standards and requirements.
05
Advocacy groups and researchers: Survey reports provide valuable data for advocacy groups and researchers studying the quality of care in nursing homes. These reports can be used to identify trends, track progress, and advocate for better policies and regulations in the industry.
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The nursing home survey report is a detailed document that provides information on the quality of care and services provided by a nursing home facility.
Nursing home administrators or authorized representatives are required to file the nursing home survey report.
The nursing home survey report must be filled out accurately and completely, including information on resident care, staffing levels, facility operations, and compliance with regulations.
The purpose of the nursing home survey report is to ensure that nursing home facilities are providing high-quality care to their residents and meeting regulatory requirements.
Information such as resident demographics, staffing ratios, health and safety inspections, and compliance with regulations must be reported on the nursing home survey report.
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