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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:2/21/2017 FORM APPROVED OMB NO. 09380391 (X3) DATE SURVEY
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Read the instructions provided with the nursing home survey report form.
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Gather all the necessary information and data needed to complete the survey report.
03
Start by filling out the demographic information section, including details about the nursing home facility.
04
Proceed to answer each question in the survey report accurately and thoroughly.
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Provide any supporting documentation or evidence when necessary.
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Who needs nursing home survey report?

01
Nursing home administrators and staff who are responsible for maintaining compliance with regulations.
02
Government agencies and regulatory bodies who oversee nursing homes and monitor their performance.
03
Healthcare professionals who need to assess the quality of care provided by nursing homes.
04
Family members or guardians of residents in nursing homes who want to ensure the facility's adherence to standards.
05
Lawyers or legal representatives involved in cases related to nursing homes.
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Researchers or academics studying the quality and effectiveness of nursing home care.
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The nursing home survey report is a document that provides information about the quality of care provided at a nursing home facility.
Nursing home administrators or owners are required to file the nursing home survey report.
To fill out the nursing home survey report, administrators or owners must provide detailed information about the facility's operations, staff qualifications, and resident care activities.
The purpose of the nursing home survey report is to ensure that nursing home facilities are providing appropriate care to their residents.
The nursing home survey report must include information on staff qualifications, resident care plans, incident reports, and other relevant data.
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