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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

Review the survey report form and guidelines provided by your state's health department.

02

Gather all necessary information such as patient records, staff schedules, and facility policies.

03

Conduct interviews with residents, staff, and family members to gather feedback and information.

04

Observe daily operations and practices within the nursing home to identify any areas of concern.

05

Document all findings accurately and thoroughly on the survey report form.

06

Submit the completed survey report to the appropriate regulatory agency.

Who needs nursing home survey report?

01

Nursing home administrators

02

Health department officials

03

Regulatory agencies

04

Quality assurance professionals

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What is nursing home survey report?

A nursing home survey report is a document that provides information about the quality of care and services provided at a nursing home facility.

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 can be filled out by providing accurate information about the care and services offered at the facility.

What is the purpose of nursing home survey report?

The purpose of the nursing home survey report is to ensure that nursing home facilities are providing quality care and services to residents.

What information must be reported on nursing home survey report?

Information such as number of residents, types of services provided, staffing levels, and any violations or deficiencies must be reported on the nursing home survey report.

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