Form preview

Get the free Statement of Deficiencies and Plan of Correction

Get Form
This document outlines the findings of a survey conducted by the Centers for Medicare & Medicaid Services (CMS) regarding the deficiencies observed at South Shore Care Center, along with the corresponding plan of correction. The survey, completed on June 4, 2019, details various areas of non-compliance including resident safety, staff training, infection control practices, and appropriate care and supervision of nursing home residents.
We are not affiliated with any brand or entity on this form

Get, Create, Make and Sign statement of deficiencies and

Edit
Edit your statement of deficiencies and form online
Type text, complete fillable fields, insert images, highlight or blackout data for discretion, add comments, and more.
Add
Add your legally-binding signature
Draw or type your signature, upload a signature image, or capture it with your digital camera.
Share
Share your form instantly
Email, fax, or share your statement of deficiencies and form via URL. You can also download, print, or export forms to your preferred cloud storage service.

How to edit statement of deficiencies and online

9.5
Ease of Setup
pdfFiller User Ratings on G2
9.0
Ease of Use
pdfFiller User Ratings on G2
In order to make advantage of the professional PDF editor, follow these steps:
1
Register the account. Begin by clicking Start Free Trial and create a profile if you are a new user.
2
Upload a file. Select Add New on your Dashboard and upload a file from your device or import it from the cloud, online, or internal mail. Then click Edit.
3
Edit statement of deficiencies and. Rearrange and rotate pages, insert new and alter existing texts, add new objects, and take advantage of other helpful tools. Click Done to apply changes and return to your Dashboard. Go to the Documents tab to access merging, splitting, locking, or unlocking functions.
4
Get your file. When you find your file in the docs list, click on its name and choose how you want to save it. To get the PDF, you can save it, send an email with it, or move it to the cloud.
Dealing with documents is simple using pdfFiller. Try it right now!

Uncompromising security for your PDF editing and eSignature needs

Your private information is safe with pdfFiller. We employ end-to-end encryption, secure cloud storage, and advanced access control to protect your documents and maintain regulatory compliance.
GDPR
AICPA SOC 2
PCI
HIPAA
CCPA
FDA

How to fill out statement of deficiencies and

Illustration

How to fill out statement of deficiencies and

01
Gather all required documentation and relevant materials.
02
Identify the specific deficiencies that need to be addressed.
03
Provide a detailed description of each deficiency, including the location and date.
04
Explain the impact of each deficiency on operations or compliance.
05
Include evidence supporting the identified deficiencies (e.g., photos, inspection reports).
06
Outline corrective actions taken or planned for each deficiency.
07
Review the completed statement for accuracy and completeness.
08
Submit the statement to the appropriate regulatory body or governing authority.

Who needs statement of deficiencies and?

01
Healthcare facilities undergoing inspections or audits.
02
Organizations seeking to improve compliance with regulations.
03
Facilities responding to compliance issues identified by regulatory bodies.
04
Management teams needing to address areas of non-compliance.
Fill form : Try Risk Free
Users Most Likely To Recommend - Summer 2025
Grid Leader in Small-Business - Summer 2025
High Performer - Summer 2025
Regional Leader - Summer 2025
Easiest To Do Business With - Summer 2025
Best Meets Requirements- Summer 2025
Rate the form
4.1
Satisfied
21 Votes

For pdfFiller’s FAQs

Below is a list of the most common customer questions. If you can’t find an answer to your question, please don’t hesitate to reach out to us.

You may quickly make your eSignature using pdfFiller and then eSign your statement of deficiencies and right from your mailbox using pdfFiller's Gmail add-on. Please keep in mind that in order to preserve your signatures and signed papers, you must first create an account.
The pdfFiller apps for iOS and Android smartphones are available in the Apple Store and Google Play Store. You may also get the program at https://edit-pdf-ios-android.pdffiller.com/. Open the web app, sign in, and start editing statement of deficiencies and.
Use the pdfFiller mobile app and complete your statement of deficiencies and and other documents on your Android device. The app provides you with all essential document management features, such as editing content, eSigning, annotating, sharing files, etc. You will have access to your documents at any time, as long as there is an internet connection.
A statement of deficiencies is a formal document that outlines specific areas where an organization or individual does not meet established standards or regulations.
Organizations or individuals that are found to be non-compliant with regulatory standards or requirements are typically required to file a statement of deficiencies.
To fill out a statement of deficiencies, one must accurately detail each area of non-compliance, provide evidence or documentation supporting the claims, and outline steps for corrective action.
The purpose of a statement of deficiencies is to clearly communicate areas needing improvement, ensure compliance with regulations, and establish a plan for corrective measures.
The information that must be reported includes a description of the deficiencies, the relevant regulations, dates of occurrence, and proposed remediation plans.
Fill out your statement of deficiencies and online with pdfFiller!

pdfFiller is an end-to-end solution for managing, creating, and editing documents and forms in the cloud. Save time and hassle by preparing your tax forms online.

Get started now
Form preview
If you believe that this page should be taken down, please follow our DMCA take down process here .
This form may include fields for payment information. Data entered in these fields is not covered by PCI DSS compliance.