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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:1/26/2017 FORM APPROVED OMB NO. 09380391 (X3) DATE SURVEY
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How to fill out nursing home survey report

01
Gather all the necessary information and documentation needed for the survey report.
02
Start by providing basic information about the nursing home such as its name, address, and contact details.
03
Include details about the survey process, including the date and time of the survey and the names of the surveyors.
04
Document any observations or findings made during the survey regarding the quality of care provided at the nursing home.
05
Make note of any deficiencies or violations observed during the survey, and provide a detailed description of each one.
06
Include recommendations for improvement or corrective actions that should be taken to address the deficiencies.
07
Ensure that all information provided is accurate, complete, and well-organized.
08
Proofread the report for any errors or inconsistencies before finalizing it.
09
Submit the completed nursing home survey report to the appropriate authorities as required.

Who needs nursing home survey report?

01
Government agencies responsible for licensing and regulating nursing homes.
02
Healthcare administrators and professionals who oversee nursing home facilities.
03
Insurance companies or organizations that provide coverage for nursing home services.
04
Advocacy groups or legal entities that work on behalf of nursing home residents.
05
Individuals or families researching or considering nursing home options for their loved ones.
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Nursing home survey report is a detailed report that assesses the quality of care provided in a nursing home by evaluating various aspects such as resident health, safety, and overall well-being.
Nursing home administrators or designated staff members are required to file the nursing home survey report.
Nursing home survey report can be filled out by providing accurate and detailed information about the facility, resident care, staff qualifications, and any incidents or complaints.
The purpose of nursing home survey report is to ensure that nursing homes are providing quality care to their residents and to identify any areas that may need improvement.
Information that must be reported on nursing home survey report includes facility demographics, resident demographics, care plans, incident reports, and compliance with regulations.
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