3 Years of Survey Inspections Date state issued letter Date of survey/inspection approving POC Key Questions Yes No Do the state surveys identify any instances of actual harm and/or immediate jeopardy (during last 3 year period)? . Are there currently any open findings? <<For each answer above, provide a narrative discussion on the topic describing the risk “yes” and how it will be mitigated. Example: General Review and Findings: Provide narrative description of review. For example: {date} state survey inspection letter indicates that “The there were X deficiencies. The deficiencies…”>> Other Facilities Operated or Managed skilled nursing facilities.>> <<This section is only applicable for Key Questions Yes No Do any state surveys identify any instances of actual harm and/or immediate jeopardy? . Are there currently any open findings at any of the facilities? <<For each answer above, provide a narrative discussion regarding the topic.>> “yes” General Review and Findings <<Provide a narrative description of review. For example, most recent state survey “The inspections are provided for XX skilled nursing facilities that are owned, operated, or managed by XXXX. The underwriter has reviewed the findings and found….”>> Staffing <<Provide narrative description of review. For example: appraiser and underwriter have “The reviewed the current and proposed staffing to be charged to the facility and found it to be acceptable and within reason…”>>
3 Years of Survey Inspections Date of survey/inspection Date state issued letter approving POC Key Questions Yes No Do the state surveys identify any instances of actual harm and/or immediate jeopardy (during last 3 year period)? . Are there currently any open findings? <<For each “yes” answer above, provide a narrative discussion on the topic describing the risk and how it will be mitigated. Example: General Review and Findings: Provide narrative description of review. For example: “The {date} state survey inspection letter indicates that there were X deficiencies. The deficiencies…”>> Other Facilities Operated or Managed <<This section is only applicable for skilled nursing facilities.>> Key Questions Yes No Do any state surveys identify any instances of actual harm and/or immediate jeopardy? . Are there currently any open findings at any of the facilities? <<For each “yes” answer above, provide a narrative discussion regarding the topic.>> General Review and Findings <<Provide a narrative description of review. For example, “The most recent state survey inspections are provided for XX skilled nursing facilities that are owned, operated, or managed by XXXX. The underwriter has reviewed the findings and found….”>> Staffing <<Provide narrative description of review. For example: “The appraiser and underwriter have reviewed the current and proposed staffing to be charged to the facility and found it to be acceptable and within reason…”>>
9008_LN-BLENDED-SINGLE-4C.DOCX