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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:9/1/2016 FORM APPROVED OMB NO. 09380391 (X3) DATE SURVEY COMPLETED

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How to fill out nursing home survey report

01

Make sure to thoroughly read the nursing home survey report form before filling it out.

02

Start by providing your personal information, such as your name, contact details, and job title.

03

Document the date and time of your visit to the nursing home.

04

Observe and assess the overall cleanliness and hygiene of the facility.

05

Evaluate the staff-to-resident ratio and note any issues or concerns.

06

Audit the safety measures and protocols in place, including emergency exits and fire safety equipment.

07

Interview residents and their families to gather their opinions and experiences.

08

Document any instances of abuse or negligence witnessed or reported.

09

Give a detailed description of the nursing home's medical care services, including medication administration and management.

10

Assess the quality of the meals provided, taking note of any special dietary requirements.

11

Evaluate the social and recreational activities available to the residents.

12

Include any recommendations or suggestions for improvement based on your assessment.

13

Submit the completed nursing home survey report to the appropriate regulatory body.

Who needs nursing home survey report?

01

Healthcare organizations and regulatory bodies that oversee nursing homes require the nursing home survey report.

02

Administrators and managers of nursing homes use the report to identify areas of improvement and ensure compliance with regulations.

03

Government agencies use the report to evaluate the quality of care provided by nursing homes and enforce regulations.

04

Insurance companies may request the report when determining coverage and reimbursement for nursing home services.

05

Families and individuals considering placing a loved one in a nursing home can benefit from reviewing the report to make informed decisions.

06

Advocacy groups and researchers may analyze the report to identify patterns or issues within the nursing home industry.

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What is nursing home survey report?

The nursing home survey report is a document that outlines the results of inspections and evaluations conducted at a nursing home facility to ensure compliance with regulations and standards.

Who is required to file nursing home survey report?

Nursing home administrators or designated staff members are required to file the nursing home survey report.

How to fill out nursing home survey report?

The nursing home survey report can be filled out by providing accurate information about the facility's operations, compliance with regulations, and any corrective actions taken.

What is the purpose of nursing home survey report?

The purpose of the nursing home survey report is to assess the quality of care and safety provided to residents, identify areas for improvement, and ensure compliance with regulations.

What information must be reported on nursing home survey report?

Information that must be reported on the nursing home survey report includes details about the facility's operations, resident care practices, staff qualifications, and any deficiencies found during inspections.

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