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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONPRINTED:2/6/2019 FORM APPROVED OMB NO. 09380391 (X3) DATE SURVEY COMPLETED(X1)

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How to fill out nursing home survey report

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Step 1: Obtain a copy of the nursing home survey report form.

02

Step 2: Read the instructions and familiarize yourself with the required information.

03

Step 3: Start by filling out the basic details of the nursing home, such as the name, address, and contact information.

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Step 4: Provide the necessary information about the residents, including their names, ages, medical conditions, and any special requirements or concerns.

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Step 5: Document any incidents or events that occurred during the survey period, such as falls, medication errors, or complaints from residents or their families.

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Step 6: Record any findings or observations made during the survey, such as the cleanliness of the facility, the quality of care provided, and the availability of necessary resources.

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Step 7: Include any recommendations or suggestions for improvements that you may have.

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Step 8: Review the completed survey report for accuracy and completeness.

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Step 9: Submit the survey report to the appropriate authorities or agencies as required.

Who needs nursing home survey report?

01

Nursing home administrators

02

Regulatory agencies responsible for overseeing nursing homes

03

Government officials involved in healthcare policy and regulation

04

Researchers or academics studying nursing home quality and safety

05

Advocacy groups or organizations focused on improving nursing home care

06

Families or individuals considering a nursing home for a loved one and seeking information about the facility's quality

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What is nursing home survey report?

Nursing home survey report is a document that provides information on the evaluation and compliance of nursing homes with regulations and standards set forth by regulatory agencies.

Who is required to file nursing home survey report?

Nursing home administrators or authorized personnel 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 and detailed information about the facility's operations, compliance with regulations, and quality of care provided to residents.

What is the purpose of nursing home survey report?

The purpose of the nursing home survey report is to ensure that nursing homes are operating in compliance with regulations and standards to ensure the safety and well-being of residents.

What information must be reported on nursing home survey report?

The nursing home survey report must include information on staffing levels, resident care plans, facility maintenance, infection control measures, and resident satisfaction.

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