Surveyor Matrix Resident Sample Worksheet

Pre-populated resident matrix worksheet to organize residents by care areas and support surveyor sample selection at entrance during a CMS long-term care survey.

Inspection Details

• Facility name
• Survey date
• Survey type
• Surveyor entrance conference time
• Matrix prepared by

Resident Census and Care Area Matrix

• Total census entered
• Residents assigned to skilled nursing / post-acute care area
• Residents receiving memory care / dementia services
• Residents receiving wound care or pressure injury treatment
• Residents receiving tube feeding, IV therapy, or other complex clinical services
• Residents with recent falls, transfers, or mobility concerns
• Residents with isolation precautions or infection control concerns
• Residents with behavioral health or psychosocial concerns

Resident Sample Readiness

• Resident identifiers are limited to internal census or room identifiers; no unnecessary PII included
• Each care area includes current resident count and location
• High-risk residents are clearly flagged for surveyor review
• Supporting clinical records can be retrieved within 10 minutes
• Interdisciplinary team contacts are listed for each care area
• Any resident transfers, discharges, or recent admissions are noted

Surveyor Sample Selection Support

• Residents likely to be selected for closed record review are identified
• Residents likely to be selected for focused clinical review are identified
• Residents likely to be selected for observation are identified
• Residents likely to be selected for interview are identified
• Matrix reflects current census changes from the last 24 hours

Findings, Deficiencies, and Sign-Off

• Deficiencies or gaps identified in the resident matrix
• Corrective actions needed before surveyor arrival
• Date corrective actions completed
• Inspector or preparer signature