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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONPRINTED:11/9/2020 FORM APPROVED OMB NO. 09380391 (X3) DATE SURVEY COMPLETED(X1)
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Obtain a copy of the nursing home survey report form
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Review the instructions provided on how to fill out the form
03
Gather all necessary information and documentation required for the report
04
Start by filling out the basic information section such as the name of the nursing home, date of the survey, and name of the surveyor
05
Carefully document any deficiencies or violations found during the survey, along with any corrective actions taken
06
Submit the completed nursing home survey report to the appropriate regulatory agency

Who needs nursing home survey report?

01
Nursing home administrators
02
Regulatory agencies
03
Government authorities responsible for overseeing nursing homes
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A nursing home survey report is an assessment conducted by regulatory agencies to evaluate the quality of care and compliance with established regulations in nursing homes. It includes findings from inspections and resident interviews.
Nursing home administrators or management are typically required to file the nursing home survey report, ensuring that all necessary information is accurately reported to regulatory bodies.
To fill out a nursing home survey report, one must gather relevant data regarding the facility's operations, staffing, resident care, and compliance with regulations, and then enter this information into the prescribed format provided by the regulatory agency.
The purpose of the nursing home survey report is to ensure that nursing homes are providing adequate care to residents by assessing compliance with health and safety standards set by regulatory authorities.
The report typically includes information about facility staffing levels, resident care practices, incident reports, compliance with regulations, and any violations or deficiencies identified during inspections.
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