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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONPRINTED:7/8/2020 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 your supervising authority.

02

Review the instructions provided with the form to understand the requirements and expectations.

03

Gather all the necessary information, including resident and facility details.

04

Fill out the survey report accurately and truthfully, using clear and concise language.

05

Double-check your entries for any errors or missing information before submitting the report.

Who needs nursing home survey report?

01

Nursing home administrators and staff

02

Regulatory agencies overseeing nursing home facilities

03

Quality assurance and compliance officers

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What is nursing home survey report?

A nursing home survey report is a document that summarizes the findings of an inspection or assessment of a nursing home to ensure compliance with health and safety regulations.

Who is required to file nursing home survey report?

The nursing home administrators and operators are typically required to file the nursing home survey report as part of regulatory compliance.

How to fill out nursing home survey report?

To fill out a nursing home survey report, follow the provided guidelines, ensure accurate information is entered, provide supporting documentation, and review for completeness before submission.

What is the purpose of nursing home survey report?

The purpose of the nursing home survey report is to evaluate the quality of care given to residents, assess compliance with regulations, and identify areas for improvement.

What information must be reported on nursing home survey report?

The nursing home survey report must include information such as resident care practices, staffing levels, safety measures, incidents, and any citations for non-compliance.

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