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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONPRINTED:5/27/2016 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: Start by downloading the nursing home survey report form from the official website.

02

Step 2: Read and understand the instructions provided with the form.

03

Step 3: Fill out the basic information section, which includes the name and address of the nursing home.

04

Step 4: Proceed to the survey questions section. Answer each question accurately and concisely.

05

Step 5: Provide additional comments or explanations, if required.

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Step 6: Review the completed form for any errors or missing information.

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Step 7: Sign and date the report.

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Step 8: Submit the filled-out nursing home survey report to the designated authority or department.

Who needs nursing home survey report?

01

Nursing home administrators

02

Regulatory agencies

03

Government bodies

04

Research institutions

05

Policy makers

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What is nursing home survey report?

Nursing home survey report is a document that provides an assessment of the quality of care and living conditions in a nursing home.

Who is required to file nursing home survey report?

Nursing home administrators or owners are required to file the nursing home survey report.

How to fill out nursing home survey report?

The nursing home survey report is typically filled out by conducting on-site inspections, interviews with staff and residents, and reviewing records.

What is the purpose of nursing home survey report?

The purpose of the nursing home survey report is to ensure that nursing homes are providing quality care to residents and meeting regulatory standards.

What information must be reported on nursing home survey report?

Information such as staffing levels, resident care plans, infection control procedures, and overall quality of life for residents must be reported on the nursing home survey report.

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