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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONPRINTED:8/10/2020 FORM APPROVED OMB NO. 09380391 (X3) DATE SURVEY COMPLETED(X1)

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How to fill out nursing home survey report

01

Obtain the nursing home survey report form from the appropriate regulatory agency.

02

Gather all necessary information such as resident demographics, quality measures, staffing levels, and any incidents or complaints.

03

Complete the report accurately and thoroughly, ensuring all required fields are filled out.

04

Review the report for any errors or omissions before submission.

05

Submit the completed nursing home survey report to the regulatory agency by the deadline.

Who needs nursing home survey report?

01

Nursing home administrators

02

Regulatory agencies

03

Healthcare professionals

04

Families of nursing home residents

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What is nursing home survey report?

Nursing home survey report is a document that provides detailed information about the quality of care provided in a nursing home and the compliance with regulations.

Who is required to file nursing home survey report?

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

How to fill out nursing home survey report?

Nursing home survey report can be filled out by providing accurate information about the care provided, resident outcomes, staffing levels, and compliance with regulations.

What is the purpose of nursing home survey report?

The purpose of nursing home survey report is to assess the quality of care provided in nursing homes and ensure compliance with regulations.

What information must be reported on nursing home survey report?

Information such as resident care, staffing levels, infection control practices, medication management, and compliance with regulations must be reported on the nursing home survey report.

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