Focused Dementia Care Surveyor Worksheets Name of State Agency: (please specify) Team Leader: Surveyors on Team: PART 1 -- NURSING HOME CHARACTERISTICS 1. Nursing Home Name 2a. Nursing Home Street Address/PO Box 2b. Nursing Home 2c. Nursing Home Zip Code 3. 6-digit CMS Certification Number 4. Date(s) of site To visit (MM/DD/YYYY) For profit part of a corporate – 5. What is the ownership of the chain For profit independent – facility? (Select only ONE) owner Not for profit Public (state or county-owned) (please specify): PART 2 -- DEMENTIA CARE POLICIES, LEADERSHIP, TRAINING, DOCUMENTATION – 6a. Does the nursing home have a specific unit or wing for residents with dementia? NO
Focused Dementia Care Surveyor Worksheets Name of State Agency: (please specify) Team Leader: Surveyors on Team: PART 1 -- NURSING HOME CHARACTERISTICS 1. Nursing Home Name 2a. Nursing Home Street Address/PO Box 2b. Nursing Home 2c. Nursing Home Zip Code 3. 6-digit CMS Certification Number 4. Date(s) of site visit (MM/DD/YYYY) To 5. What is the ownership of the facility? (Select only ONE) For profit – part of a corporate chain For profit – independent owner Not for profit Public (state or county-owned) (please specify): PART 2 -- DEMENTIA CARE – POLICIES, LEADERSHIP, TRAINING, DOCUMENTATION 6a. Does the nursing home have a specific unit or wing for residents with dementia? NO
SC16-04-02-Attach1-FacilityQuestions.docx