Survey Readiness Checklists

State Operations Manual Appendix PP — entrance conference

What the survey team asks for in the first hour. Keep it current, not assembled in a panic.

• Alphabetical resident census with room numbers and payer source
• Matrix of residents with pressure ulcers, restraints, dialysis, hospice, isolation and behavioral health needs
• Facility assessment, current and dated within the last 12 months
• Written QAPI plan available on request
• Infection prevention and control program, surveillance log and antibiotic stewardship protocols
• Name of the infection preventionist and evidence of specialized training
• Admission packet including rights, rules, bed-hold and grievance information
• Current list of licensed staff with license numbers and expiration dates
• Schedules for the last four weeks and the current posted staffing notice
• Meal times, medication pass times and unit floor plan
• Dialysis, hospice and other contracted-service agreements
• Resident and family council meeting minutes for the past year
• Actual and expected census, plus admissions and discharges for the last 30 days

F800, F804, F812, F813 — 42 CFR 483.60

F812 is one of the highest-frequency citations in the country. Round it weekly.

• Refrigerator temperatures logged and within range; freezer at or below 0°F
• Hot holding at or above 135°F and cold holding at or below 41°F verified at tray line
• All stored food labeled with contents and use-by date, and stored 6 inches off the floor
• No expired, dented, bulging or unlabeled items in dry storage or reach-ins
• Dish machine wash and rinse temperatures or sanitizer concentration logged each meal
• Three-compartment sink set up correctly with test strips available
• Staff hand hygiene, hair restraints, gloves and no jewelry beyond a plain band
• Ice machine clean, scoop stored outside the bin
• Food thermometers calibrated and sanitized between uses
• Therapeutic and texture-modified diets match the current physician orders
• Resident food preferences, substitutions and dislikes honored at the table
• Dining assistance provided per care plan, residents positioned upright
• Meal times match posted times; no more than 14 hours between the evening meal and breakfast
• Emergency food and water supply on hand for the planned duration

F880, F881, F882, F883 — 42 CFR 483.80

The most cited tag nationally. Surveyors observe practice, not policy.

• Hand hygiene performed before and after every resident contact and between glove changes
• PPE stocked at the point of use and donned and doffed in the correct order
• Isolation signage present, accurate and matched to the resident's precautions
• Surveillance log current, with case definitions and monthly trending
• Antibiotic stewardship protocols in use; culture results reviewed and prescribers given feedback
• Infection preventionist designated, trained and attending QAA meetings
• Clean and soiled utility rooms clearly separated, doors closed and secured
• Glucometers, blood pressure cuffs and lifts disinfected between residents
• Linen carts covered; soiled linen bagged at the point of use
• Influenza and pneumococcal vaccination status documented, including refusals
• Staff illness and work restriction policy followed and documented
• Wound care and catheter care observed for aseptic technique

F550–F586 — 42 CFR 483.10

Dignity findings come from what surveyors overhear in a hallway.

• Residents addressed by their preferred name; no talking over residents during care
• Doors and privacy curtains closed during care; bodies covered during transport
• Call lights within reach and answered promptly; response times monitored
• Grievance process posted with the grievance official's name and contact
• Ombudsman, state survey agency and advocacy contact information posted
• Resident council minutes show facility responses to concerns in writing
• Residents dressed appropriately for the time of day, groomed, nails and hair cared for
• Personal mail delivered unopened and telephone access is private
• Activities calendar posted and actually running as scheduled
• Room and roommate change notification documented
• Residents' funds accounts reconciled with quarterly statements provided
• Advance directives documented and consistent across the record

F636, F655, F656, F657, F684, F842

Timing rules drive most record citations — and most exam questions.

• Baseline care plan completed within 48 hours of admission with a written summary given to the resident
• Comprehensive MDS completed within 14 days of admission and annually
• Comprehensive care plan completed within 7 days after the comprehensive assessment
• Significant change assessment completed within 14 days of identification
• Care plans person-centered, with measurable goals and resident participation documented
• Physician orders match the MAR and TAR; no unsigned telephone orders past the deadline
• Change-in-condition notifications to physician and representative documented with time
• Weights recorded per schedule; variances investigated and addressed
• PRN psychotropic orders limited to 14 days unless rationale is documented
• Pharmacist drug regimen review completed monthly with irregularities acted on
• Records complete, accurately documented, readily accessible and systematically organized
• Records retained 5 years, or 3 years past the age of majority for a minor

F689, F906, F908, F919, F921 — 42 CFR 483.70/483.90

Walk the building the way a surveyor does: on the perimeter first, then the units.

• Exits unobstructed; corridors clear of unattended carts and equipment
• Fire doors close and latch; no doors propped or wedged
• Sprinkler heads clean and unobstructed; 18-inch clearance maintained
• Fire extinguisher inspections current and documented monthly
• Generator tested and load-tested per schedule with fuel supply documented
• Water temperatures at resident sinks within the safe range and logged
• Chemicals and hazardous items secured; SDS sheets accessible
• Medication carts and rooms locked when unattended; controlled substances reconciled
• Oxygen cylinders secured and stored with signage
• Call system functional from every bed, bath and toilet area
• Resident room temperatures maintained in the required range
• Elopement risk residents identified; door alarms and WanderGuards tested
• Preventive maintenance logs current for essential equipment
• Water management program for Legionella documented and monitored