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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:1×12/2016 FORM APPROVED OMB NO. 09380391 (X3) DATE SURVEY
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How to fill out nursing home survey report

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How to fill out a nursing home survey report:

01
Begin by gathering all necessary information, such as the name of the nursing home, the date of the survey, and the names of the surveyors.
02
Conduct a thorough inspection of the nursing home, noting any areas of concern or violations of regulations. Take detailed notes and gather evidence, such as photographs or witness statements.
03
Review all relevant documentation, including the nursing home's policies and procedures, patient records, and incident reports. Analyze this information to identify any potential issues or areas for improvement.
04
Use a standardized nursing home survey report form provided by your regulatory agency. Fill out the form accurately and completely, including sections on resident rights, quality of care, infection control, and facility maintenance.
05
Clearly document any deficiencies or violations discovered during the survey. Provide specific details and examples to support your findings.
06
If possible, meet with the nursing home staff to discuss your findings and give them an opportunity to address any concerns or provide explanations.
07
Submit the completed survey report to your regulatory agency within the designated timeframe. Include any supporting documentation or evidence.
08
Follow up with the nursing home to ensure that any deficiencies identified in the report are addressed and corrected.

Who needs a nursing home survey report?

01
Regulatory agencies: Nursing home survey reports are typically required by government regulatory agencies to assess the compliance of nursing homes with regulations and standards of care. These reports help authorities determine if the nursing home is providing a safe and adequate living environment for its residents.
02
Nursing home administrators: Survey reports provide valuable feedback to nursing home administrators, as they highlight areas where improvements need to be made and help identify potential risks or noncompliance issues. Administrators can use this information to implement corrective actions and ensure the overall well-being of their residents.
03
Residents and their families: Survey reports can help residents and their families make informed decisions regarding nursing home selection. By reviewing survey reports, they can better understand the quality of care provided at different nursing homes and choose a facility that meets their expectations and care needs.
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Nursing home survey report is a detailed document that assesses the quality of care provided in a nursing home facility.
Nursing home administrators are required to file the nursing home survey report.
The nursing home survey report can be filled out online through a designated portal provided by the regulatory agency.
The purpose of the nursing home survey report is to ensure that nursing home facilities are providing quality care to their residents.
The nursing home survey report must include information on staffing levels, resident care plans, and compliance with regulatory requirements.
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