Form Cms-805 - Resident Review Worksheet
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4DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
RESIDENT REVIEW WORKSHEET
Facility Name:__________________________________________
Resident Name: _____________________________________
Provider Number: _______________________________________
Resident Identifier: __________________________________
Surveyor Name: ________________________________________
Birthdate: __________
Unit:________ Rm #:_____________
Surveyor Number:____________ Discipline:_________________
Orig. Admission Date:________ Readmission Date:________
Survey Date: _______________________________________
Payment Source: Admission: __________________________
Current: _____________________________
Diagnosis: ___________________________________________________________________________________________________
____________________________________________________________________________________________________________
Interviewable:
Yes
No
Type of Review:
Comprehensive
Focused
Closed Record
Selected for Individual Interview:
Yes
No
Selected for Family Interview and Observation of Non-Interviewable Resident:
Yes
No
Focus/Care Areas:____________________________________________________________________________________________
___________________________________________________________________________________________________________
Instructions: Any regulatory areas related to the sampled resident’s needs are to be included in this review.
• Initial that each section was reviewed if there are no concerns.
• If there are concerns, document your investigation.
• Document all pertinent resident observations and information from resident, staff, family interviews and record
reviews for every resident in the sample.
SECTION A: RESIDENT ROOM REVIEW: Evaluate if appropriate requirements are met in each of the following areas,
including the accommodation of needs:
•
Adequate accommodations are made for resident privacy,
•
Environment is homelike, comfortable and attractive;
including bed curtains.
accommodations are made for resident personal items and
his/her modifications.
•
Call bells are functioning and accessible to residents
•
Bedding, bath linens and closet space is adequate for
•
Resident is able to use his/her bathroom without difficulty.
resident needs.
•
Adequate space exists for providing care to residents.
•
Resident care equipment is clean and in good repair.
•
Resident with physical limitations (e.g., walker, wheelchair)
•
Room is safe and comfortable in the following areas:
is able to move around his/her room.
temperature, water temperature, sound level and lighting.
THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.)_____
Document concerns and follow-up on Surveyor Notes sheet page 4.
SECTION B: RESIDENT DAILY LIFE REVIEW: Evaluate if appropriate requirements are met in each of the following areas:
•
Resident appears well groomed and reasonably attractive
•
Facility activities program meets resident’s individually
(e.g., clean clothes, neat hair, free from facial hair).
assessed needs and preferences.
•
Staff treats residents respectfully and listens to resident
•
Medically related social services are identified and provided
requests. Note staff interaction with both communicative
when appropriate.
and non-communicative residents.
•
Restraints are used only when medically necessary.
•
Staff is responsive to resident requests and call bells.
(see 483.13(a))
•
Residents are free from unexplained physical injuries and
•
Resident is assisted with dining when necessary.
there are no signs of resident abuse. (e.g. residents do not
appear frightened around certain staff members.)
THERE ARE NO IDENTIFIED CONCERNS FOR THESE REQUIREMENTS (Init.)_____
Document concerns and follow-up on Surveyor Notes sheet page 4.
Form CMS-805 (10/10)
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Parent category: Medical