Dates, Times, Numbers, Measurements
According to the Principles of Documentation, surveyors should document June 29, 2026 in this date format
What is 06/29/2026?
According to the Principles of Documentation, surveyors should use this tense when describing survey observations
What is past tense?
This is arguably the most important sentence in the citation. It summarizes the heart of the deficiency in one concise statement. When well-written, it allows a reader to understand immediately what the problem is without reading the detailed findings.
What is a Deficient Practice Statement?
True or False:
Hashtags or the pound sign (#) should be used when identifying the client/ resident/ patient
False
Ex: Resident (R) 1
The Housekeeper stated that he cleans resident rooms daily.
What is wrong with this sentence? (Hint: 2 things)
1. Missing date and time
Interviews should always have a date and time.
2. Housekeeper needs an identifier.
Most likely there is more than one housekeeper working at the facility, so an identifier should be applied (ex: Housekeeper AA).
According to the Principles of Documentation, surveyors should document 7 o' clock in the morning in this time format
What is 7:00 AM?
True or False:
According to the Principles of Documentation, surveyors should write in third person, avoiding the use of "I" or "we."
True
This is a term that identifies what happened or could happen because of a facility failure
What is an outcome or potential outcome?
This term identifies people in a citation
What is an identifier?
An observation on 07/01/2026 at 1:00 PM revealed staff members passing out meal trays to residents during lunch. Staff CC was observed sneezing into his hands and did not wash hands prior to passing a tray to Resident (R) 1. Staff DD was observed taking the trash out and did not wash hands prior to passing a tray to R2.
What is wrong in these sentences? (Hint: 2 things)
1. Staff CC should have a title/abbreviation
2. Staff DD should have a title/abbreviation
While the application of the identifier codes were correct, it is unclear what positions Staff CC and Staff DD hold, which could help determine the extent of the deficient practice. For example, Staff CC could be a CNA or RN, and Staff DD could be in a different department such as housekeeping. Clearly identifying these positions can strengthen the citation, as the deficient practice of failure to wash hands may indicate a more systemic issue if the positions were clear.
According to the Principles of Documentation, surveyors should spell out these numbers (unless they are attached to a unit)
What are numbers one through nine?
This type of comma is placed before the "and" in a sentence separating items in a list and helps provides clarity
What is the Oxford comma?
This term quantifies how many cases/residents/patients/clients are affected
What is an extent or scope?
Each survey report (2567) begins with this and sets the context for the survey
What is Initial Comments?
An interview on 7/1/26 at 1:05 PM with Certified Nursing Assistant (CNA) CC confirmed that he sneezed into his hands and did not wash them prior to passing a tray to R1. CC stated that he should have washed his hands, and poor hand hygiene could cause residents to become sick or lead to an outbreak.
What is wrong in these sentences? (Hint: 2 things)
1. The date should be 07/01/2026
2. CNA should be paired with CC
While the position title, abbreviation, and identifier were correctly introduced, the abbreviation “CNA” should also be paired with the identifier “CC” for following references. This ensures clarity and consistency about which staff member is referred to and what position the staff member holds.
True or False: Surveyors should use the word "percent" instead of using the % symbol when writing out findings
True
True or false:
All medical diagnoses should be capitalized in a citation
False
Medical diagnoses: Do not capitalize medical conditions except those with proper noun parts. Examples: “diabetes mellitus” (no caps), “tuberculosis” (no, unless starting sentence), “Alzheimer’s disease” (yes cap A because it’s named after Dr. Alzheimer), “Parkinson’s disease” (P capital), etc.
These 3 components are what surveyors use to determine evidence in an investigation
What is record review, interview, and observation?
This scope/severity is considered an immediate or serious threat with substantial risk of serious harm or actual serious harm/death
What is Category 1 or IJ Level (J, K, L)?
Interview with administrator BB on 07/01/2026 at 12:00 PM revealed that he expects certified medication aides and nurses to follow physician orders.
What is wrong with this sentence? (Hint: 2 things)
1. Administrator does not need an identifier.
If referring to a unique position that only one staff member holds (such as Administrator or Director of Nursing), an identifier is not needed.
2. Administrator should be capitalized.
Formal titles when referring to a specific person such as the Administrator must be capitalized.
According to the Principles of Documentation, which of the following phrases applies the correct numbering format for surveyors?
A. 3 residents
B. eleven residents
C. 1000 employees
D. five milliliters
A. 3 residents
True or False:
All job titles should be capitalized in a citation, even when speaking generally
False
Job titles: Capitalize them when referring to a specific person by title (Administrator, Director of Nursing). If speaking generally, you can lowercase (e.g., “All certified nursing assistants receive training”, here it’s generic).
What is the preferred amount of sentences the Deficient Practice Statement should be?
One
Keep it one sentence if possible: It might be long, but it should be one coherent sentence. Semicolons can be used if needed, but often commas and conjunctions suffice. If it gets lengthy or too complex, break into two sentences max, where first is “Based on…” and second starts with the actio
This format is used to identify Confidential Individuals in a citation
What is Confidential Individual (CI) A1, CI B2, etc. ?
An interview on 7/01/2026 at 3:38 pm with Confidential Individual (CI) AA revealed that staff often take over 30 minutes responding to call lights.
What is wrong with this sentence? (Hint: 3 things)
1. The date should be 07/01/2026
2. The time should have PM capitalized
3. Confidential interviews should be documented as Confidential Individual (CI) A1, CI B2, CI C3, etc.