Va Form 10-3567 - State Home Inspection-Staffing Profile Page 3

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NAME OF HOME
DATE OF INSPECTION
NURSING SERVICE STAFFING PATTERN
(Four Week Average)
HOSPITAL (Average hours Hosp.
)
PART III
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SHIFT
RN
LPN NA
RN LPN NA
RN LPN NA
RN LPN NA
RN LPN NA
RN LPN NA
RN LPN NA
DAY
EVENING
NIGHT
NURSING HOME (Average hours NHC
)
PART IV
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SHIFT
RN
LPN NA
RN LPN NA
RN LPN NA
RN LPN NA
RN LPN NA
RN LPN NA
RN LPN NA
DAY
EVENING
NIGHT
DOMICILIARY (Average hours Dom.
)
PART V
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SHIFT
RN
LPN NA
RN LPN NA
RN LPN NA
RN LPN NA
RN LPN NA
RN LPN NA
RN LPN NA
DAY
EVENING
NIGHT
VA FORM
10-3567
Page # of ##
JUL 2006

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