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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:9/20/2016 FORM APPROVED OMB NO. 09380391 (X3) DATE SURVEY
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How to fill out nursing home survey report

01
Start by thoroughly reviewing the survey report form provided by the nursing home.
02
Begin filling out the report by accurately documenting the facility's name, address, and contact information.
03
Include the date of the survey and the names of the surveyors involved.
04
Next, carefully describe the scope of the survey, such as whether it covers the entire nursing home or specific units.
05
Document any deficiencies or violations observed during the survey, ensuring to provide specific details and evidence.
06
Include the potential harm level associated with each deficiency.
07
Describe any corrective actions taken by the facility to address the deficiencies.
08
If applicable, summarize any complaints received during the survey and the facility's response.
09
Finally, sign and date the survey report, ensuring that all required sections are completed.
10
Review the report for accuracy and make any necessary corrections before finalizing it.

Who needs nursing home survey report?

01
Healthcare administrators and managers
02
Government regulatory agencies
03
Nursing home operators and owners
04
Certification bodies and accreditation organizations
05
Lawyers and legal professionals
06
Insurance companies
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The nursing home survey report is a document that provides an overview of the findings from inspections and evaluations conducted at nursing homes to ensure compliance with regulations and standards.
Nursing home administrators or designated representatives are typically responsible for filing the nursing home survey report.
The nursing home survey report can be filled out by providing detailed information about the facility, its operations, and compliance with regulations. The report may also include findings from inspections and evaluations.
The purpose of the nursing home survey report is to assess the quality of care provided at the facility, identify areas of improvement, and ensure compliance with regulations to protect the health and safety of residents.
The nursing home survey report must include information about the facility's operations, compliance with regulations, findings from inspections and evaluations, and any deficiencies or areas of improvement identified.
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