Run Surveyor Matrix Resident Sample Worksheet — Free

Inspection Details

Facility name critical (required)

Survey date critical (required)

Survey type critical (required)

Surveyor entrance conference time

Matrix prepared by

Resident Census and Care Area Matrix

Total census entered critical (required)

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 critical (required)

Yes No N/A

Each care area includes current resident count and location critical (required)

Yes No N/A

High-risk residents are clearly flagged for surveyor review critical (required)

Yes No N/A

Supporting clinical records can be retrieved within 10 minutes critical (required)

Yes No N/A

Interdisciplinary team contacts are listed for each care area

Yes No N/A

Any resident transfers, discharges, or recent admissions are noted

Yes No N/A

Surveyor Sample Selection Support

Residents likely to be selected for closed record review are identified

Yes No N/A

Residents likely to be selected for focused clinical review are identified

Yes No N/A

Residents likely to be selected for observation are identified

Yes No N/A

Residents likely to be selected for interview are identified

Yes No N/A

Matrix reflects current census changes from the last 24 hours critical (required)

Yes No N/A

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

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Run: Surveyor Matrix Resident Sample Worksheet

Inspection Details

Resident Census and Care Area Matrix

Resident Sample Readiness

Surveyor Sample Selection Support

Findings, Deficiencies, and Sign-Off

Get your results