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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONPRINTED:7/6/2017 FORM APPROVED OMB NO. 09380391 (X3) DATE SURVEY COMPLETED(X1)
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01
To fill out a nursing home survey report, follow these steps:
02
Begin by reviewing the entire form to understand its sections and requirements.
03
Gather necessary information such as the name and address of the nursing home, the date of the survey, and the surveyor's name.
04
Start filling out the report by answering each question or providing the required information accurately.
05
Use clear and concise language while responding. Avoid providing vague or incomplete answers.
06
Provide detailed descriptions when necessary, especially when reporting any issues or concerns.
07
Follow any specific instructions or guidelines provided within the survey report form.
08
Make sure to answer all mandatory questions and leave no sections blank.
09
Review your completed report for any errors or missing information before submitting.
10
Sign and date the report, indicating your validation as the surveyor.
11
Submit the filled-out nursing home survey report to the relevant authority or department as instructed.

Who needs nursing home survey report?

01
Various entities and individuals may need a nursing home survey report, including:
02
- Government regulatory bodies responsible for monitoring and evaluating nursing home facilities.
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- Healthcare professionals or organizations involved in assessing the quality of care provided by nursing homes.
04
- Researchers or analysts studying trends or issues related to nursing home care.
05
- Legal entities involved in litigation or disputes related to nursing home operations or resident care.
06
- Nursing home administrators or managers who want to evaluate their facility's performance and areas for improvement.
07
- Families or individuals seeking information on the quality and safety of potential nursing home options for a loved one.
08
- Policy makers or government officials making informed decisions about nursing home regulations or funding.
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The nursing home survey report is a document that provides detailed information about the quality of care provided at a nursing home facility.
Nursing home administrators or designated staff members are required to file the nursing home survey report.
The nursing home survey report can be filled out electronically or on paper, and must include information about the facility's compliance with federal and state regulations.
The purpose of the nursing home survey report is to ensure that nursing home facilities are providing appropriate care to residents and meeting all regulatory requirements.
The nursing home survey report must include information about staffing levels, resident care plans, infection control practices, and any deficiencies found during inspections.
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