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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONPRINTED:8/22/2017 FORM APPROVED OMB NO. 09380391 (X3) DATE SURVEY COMPLETED(X1)
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01
Begin by thoroughly reviewing the nursing home survey report form.
02
Identify each section and understand the information required for each section.
03
Gather all necessary documentation and information regarding the nursing home and its operations.
04
Start with the general information section and provide accurate details about the nursing home.
05
Proceed to the individual sections such as staffing, resident care, environment, safety, etc.
06
Fill out each section accurately and provide detailed explanations where necessary.
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Ensure that all data provided is factual and verifiable.
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Submit the filled-out nursing home survey report to the relevant authority or organization as instructed.
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Keep a copy of the report for future reference or documentation purposes.

Who needs nursing home survey report?

01
Nursing home administrators
02
Government regulatory agencies
03
Healthcare quality improvement organizations
04
Accreditation bodies
05
Legal entities involved in nursing home-related cases
06
Researchers studying nursing home standards and practices
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Nursing home survey report is a detailed document that records the findings of inspections conducted at nursing homes to assess their compliance with regulations and quality of care provided to residents.
Nursing home administrators or owners are typically required to file the nursing home survey report.
To fill out the nursing home survey report, administrators or owners must provide accurate information about the facility's operations, staff, and patient care.
The purpose of the nursing home survey report is to ensure that nursing homes are providing quality care and complying with regulations to protect the well-being of residents.
Information such as staffing levels, facility cleanliness, resident care plans, and any violations of regulations must be reported on the nursing home survey report.
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