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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:11/10/2016 FORM APPROVED OMB NO. 09380391 (X3) DATE SURVEY
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01
Start by reading the survey report form carefully to familiarize yourself with the questions and instructions.
02
Collect all necessary information such as resident details, facility information, and specific incidents or events related to the survey.
03
Take your time to accurately document your observations and findings. Use concise and clear language.
04
Ensure that all sections of the survey report are completed accurately and thoroughly.
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Support your observations with any relevant documentation or evidence.
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Take note of any violations or areas of concern that need to be reported.
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Review and revise your answers for clarity and accuracy before submitting the survey report.
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Make a copy of the completed survey report for your records.
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Submit the survey report to the appropriate authority or department within the designated timeframe.

Who needs nursing home survey report?

01
Healthcare professionals working in nursing homes or long-term care facilities.
02
Government regulatory agencies responsible for overseeing nursing homes.
03
Quality assurance teams within nursing homes.
04
Legal professionals involved in cases related to nursing home care.
05
Advocacy groups focusing on improving nursing home standards.
06
Insurance companies evaluating nursing homes for coverage purposes.
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The nursing home survey report is a detailed document that evaluates the quality of care provided in a nursing home, including assessments of health and safety standards, resident satisfaction, and staff qualifications.
Nursing home administrators or operators are required to file the nursing home survey report with the appropriate regulatory agency.
The nursing home survey report must be filled out by documenting observations, assessments, and evaluations conducted by trained surveyors during on-site visits to the nursing home facility.
The purpose of the nursing home survey report is to ensure compliance with regulatory standards, identify areas for improvement, and promote quality care for residents.
Information reported on the nursing home survey report includes findings from inspections, evaluations of care practices, resident feedback, and details of any deficiencies or violations found.
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