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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:1/13/2017 FORM APPROVED OMB NO. 09380391 (X3) DATE SURVEY
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How to fill out nursing home survey report

01
Start by reviewing the survey report form provided by the nursing home.
02
Gather all necessary documentation, such as resident records, incident reports, and staff records.
03
Carefully read each question on the survey report form and understand the requirements.
04
Document your observations and findings accurately and objectively.
05
Use clear and concise language when describing incidents, observations, and interviews.
06
Include specific details and examples to support your findings.
07
Make sure to follow any guidelines or instructions provided by the survey organization.
08
Double-check your completed report for any errors or omissions before submitting it.
09
If you have any questions or need assistance, consult with a supervisor or experienced colleague.

Who needs nursing home survey report?

01
Nursing home administrators and staff who are responsible for maintaining compliance with regulations and standards.
02
Government agencies and auditors who assess the quality of care provided by nursing homes.
03
Families and loved ones of nursing home residents who want to ensure the safety and well-being of their loved ones.
04
Legal professionals and advocacy groups who may be investigating issues related to nursing home care.
05
Insurance companies and healthcare providers who need to assess the quality of care provided by nursing homes.
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The nursing home survey report is a detailed evaluation of a nursing home's compliance with state and federal regulations.
Nursing homes are required to file the survey report to ensure they are meeting all necessary standards of care.
The survey report can be filled out by trained inspectors who assess the nursing home's facilities, staff, and resident care practices.
The purpose of the survey report is to ensure nursing homes are providing safe and adequate care to their residents.
Information such as facility cleanliness, staff training, resident health and safety, and compliance with regulations must be reported on the survey.
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