Form Cms-803 - General Observations Of Facility printable pdf download

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

GENERAL OBSERVATIONS OF THE FACILITY

Facility Name: _______________________________________ Surveyor Name:_________________________________

Provider Number:____________________________________ Surveyor Number:_________ Discipline:___________

Observation Dates: From _______________To____________

Instructions: Use the questions below to focus your observations of the facility. Include all locations used by residents

(units, hallways, dining rooms, lounges, activity and therapy rooms, bathing areas, and resident smoking areas). Also check

other areas that affect the residents, such as storage and utility areas. Initial that there are no concerns or note concerns and

your follow-up in the space provided. Begin your observations as soon as possible after entering the facility and continue

throughout the survey. Note, these tags are not all inclusive.

LIST ANY POTENTIAL CONCERNS FROM OFFSITE SURVEY PREPARATION.___________________________

___________________________________________________________________________

1. HANDRAILS: Do corridors have handrails? Are handrails affixed to walls, intact, and free of splinters? (F468)

2. ODORS: Is the facility free of objectionable odors? Are resident areas well ventilated? Especially observe activity

areas and the dining room during activities and lunch, when the residents are using them. Are nonsmoking areas smoke

free? Do smoking areas provide good quality of life for residents who smoke? (F252)

3. CLEANLINESS: How clean is the environment (walls, floors, drapes, furniture)? (F252)

4. PESTS: Is the facility pest free? (F469)

5. LINEN: Is the linen processed, transported, stored and handled properly to prevent the spread of infection? (F445)

6. HAZARDS: Is the facility as free of accident hazards as possible? Are water temperatures safe and comfortable? Are

housekeeping/hazards, compounds, and other chemicals stored to prevent resident access? (F252, 323)

7. CALL SYSTEM: Is there a functioning call system in bathing areas and resident toilets in common areas? (F463)

8. SPACE: Do the space and furnishings in dining and activity areas appear sufficient to accommodate all activities? (F464)

9. FURNISHINGS: Are dining and activity rooms adequately furnished? (F464)

10. DRUG STORAGE: Are drugs and biologicals stored properly (locked and at appropriate temperatures)? (F432)

11. EQUIPMENT: Is the resident equipment in common areas sanitary, orderly, and in good repair? (Equipment in therapy

rooms, bathing rooms, activity areas, etc.) Are equipment and supplies appropriately stored and handled in clean and

dirty utility areas (sterile supplies, thermometer, etc.)? (F253)

12. EQUIPMENT CONDITION: [Excluding the kitchen] Is essential equipment in safe and effective operating

condition (e.g. boiler room equipment, nursing unit/medication room equipment, unit refrigerators, laundry equipment,

therapy equipment)? (F456)

13. SURVEY POSTED: Are survey results readily accessible to residents? Are the survey results or a notice concerning

survey results posted? (F167)

14. INFORMATION POSTED: Is information about Medicare, Medicaid and contacting advocacy agencies posted? (Fl56)

15. POSlTlONING: Is correct posture and comfortable positioning and assistance being provided to residents who need

assistance — especially check residents who are dining or participating in activities? (F246, 311, 318)

16. EMERGENCY: Are staff prepared for an emergency or disaster? Ask two staff and a charge nurse to describe what

they do in emergencies (include staff from different shifts). Evaluate the responses to determine their correctness and

preparedness. (F518)

17. EMERGENCY POWER: Is there emergency power? Are staff aware of outlets, if any, powered by emergency source? (F455)

18. WASTE: Is waste contained in properly maintained (no breaks) cans, dumpsters or compactors with covers? (F454, 371)

THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.)________

Document concerns and follow-up on back of page:

Form CMS-803 (7-95)

Form Cms-803 - General Observations Of Facility

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