Nursing home survey-readiness checklist

A nursing home survey-readiness checklist should connect each open issue to a responsible person, a current record and a follow-up date. Start with your last survey findings, staff credentials, policy records and QAPI follow-through. Use the printable working aid above to record gaps and evidence locations before choosing which work needs attention first.

This is a suggested internal review for administrators and Directors of Nursing. It is not the CMS entrance-conference checklist, a complete regulatory audit or a prediction of your survey result. It covers the federal nursing-home context; state requirements and assisted living licensing need a separate review.

Start with the current survey resources

Keep a link to CMS’s nursing home survey resources, which include the Long-Term Care Survey Process materials. Check the current files and your agency’s instructions when preparing requested records. A saved checklist can become outdated; assign someone to check its version.

Six checks for your next administrator–DON review

1. Survey findings and corrections. Reconcile the last CMS-2567 with your correction records. For each open item, record the owner, next action, due date and evidence location. Keep submission, acceptance and verification statuses separate. Use the Plan of Correction worksheet when you need a finding-by-finding response.
2. Staff records. Check the roster against the people actually working, including agency staff where applicable. Identify missing credential evidence, approaching expirations and the person responsible for confirming renewals. Use your license-specific requirements; a reminder alone does not verify a credential.
3. Policies and supporting records. Check that the responsible staff can retrieve the current version and explain how it is used. Record missing approvals, outdated copies and evidence that a revised process reached the people doing the work. Keep resident and employee details in your approved records system.
4. QAPI follow-through. Connect identified problems with the action taken and the next check of whether it worked. CMS’s five-element QAPI framework links governance, monitoring and improvement. A calendar entry alone does not show that an improvement was sustained. Read the QAPI guide for the framework and requirements.
5. Staffing-report evidence. Identify the PBJ submission owner and backup. Record where payroll reconciliation, agency records and the final validation report are kept. Use the PBJ reporting checklist for submission details and current deadlines.
6. Record retrieval and handoff. Ask someone other than the usual owner to locate a sample of the records you expect to need. Note access problems, missing context and work that has no backup. Follow your facility’s access controls and the survey team’s actual requests.

Turn a gap into a trackable action

Use five fields: issue, owner, next action, due date and evidence reference. Add the review date and outcome when the check happens. If evidence is missing, record that fact instead of treating an unchecked box as proof of compliance. Escalate issues through your facility’s established process; an immediate safety concern should not wait for the next routine review.

Illustrative example: “Current policy review record not located; administrator to confirm the approved version and record its location; review at the next agreed check-in.” This example describes a documentation task, not a finding about a real facility.

Choose a review rhythm your team can maintain

A short weekly review of open actions and a broader monthly record check can be a starting point for your team. These are suggested working intervals, not universal CMS deadlines. Adjust the frequency to the risk, your correction commitments, applicable requirements and changes at the facility. Record who covers the review when the usual owner is away.

Decide whether you need another tool

If your spreadsheet already has clear owners, current evidence and reliable follow-up, keep what works. If records live in several places and updates depend on one person, compare what another tool would actually change. Our comparison of spreadsheets, templates, consultants and software and product walkthrough help you check the fit. Use the 30-day pilot evaluation to test the same tasks against your existing process.