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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:5/27/2016 FORM APPROVED OMB NO. 09380391 (X3) DATE SURVEY
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How to fill out nursing home survey report

01
Gather all necessary information about the nursing home such as its name, location, and contact details.
02
Familiarize yourself with the specific requirements and guidelines provided for filling out the survey report.
03
Start by entering the resident's personal information including their name, age, and medical history.
04
Document any observations or concerns regarding the resident's living conditions, hygiene, and overall well-being.
05
Record the staff's behavior, quality of care provided, and any instances of neglect or abuse.
06
Include detailed descriptions of any incidents or accidents that have occurred within the nursing home.
07
Take note of any necessary improvements or recommendations for the nursing home's facilities or services.
08
Ensure all information provided is accurate, objective, and supported by relevant evidence.
09
Proofread the survey report for any errors or inconsistencies before submitting it.
10
Submit the completed survey report to the appropriate authority or organization responsible for monitoring nursing homes.
11
Keep a copy of the survey report for your records.

Who needs nursing home survey report?

01
Nursing home administrators and staff who need to evaluate the quality of care provided in their facility.
02
Government regulatory bodies responsible for monitoring and ensuring compliance of nursing homes with standards and regulations.
03
Investors or potential investors who want to assess the reputation and quality of a nursing home before making any decisions.
04
Legal representatives or attorneys who may require nursing home survey reports as evidence in cases related to negligence, abuse, or malpractice.
05
Healthcare organizations or agencies involved in licensing, accreditation, or certification of nursing homes.
06
Families or individuals seeking to choose a nursing home for themselves or their loved ones and want to make an informed decision based on objective data.
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Nursing home survey report is a document that assesses the compliance of a nursing home with regulations and standards set by governing bodies.
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 information about the facility's operations, resident care, staff, and compliance with regulations.
The purpose of the nursing home survey report is to ensure that nursing homes are providing adequate care to their residents and following regulations.
Information such as resident care plans, staff qualifications, infection control protocols, and safety measures must be reported on the nursing home survey report.
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