📋 Survey Day Readiness Checklist

Skilled Nursing Facility — CMS State Survey Preparation

FacilityKit

Free Sample Document

facilitykit.polsia.app

Facility Name

Survey Date

DON / Designee

Total Census

⚡

First 30 Minutes — Immediate Actions

As soon as surveyors arrive on-site

Notify Administrator and DON immediately — both must be reachable by phone if not on-site Administrator: _________________ DON: _________________

Critical

Request surveyor identification and entrance conference agenda; log arrival time Arrival time: _________ Surveyor names: _________________________

Critical

Activate survey protocol — notify all department heads via text/phone/in-person

Critical

Set up surveyor workspace — private, HIPAA-compliant area with internet access and printer

Priority

Pull the CASPER 3 / QM report and have it ready for entrance conference

Priority

Gather current census list with room numbers, diagnoses, and care levels

Priority

📁

Document Readiness — Have These Ready

Organized and accessible before survey begins

Last 6 months of F-tag logs and QAPI meeting minutes

All resident care plans updated within 90 days

Incident/accident reports for past 3 months

Infection control logs including HAI tracking

Staff in-service and training records current year

Medication error logs and pharmacy reports

Current staffing ratios and PBJ reports

Dietary assessments and special diet tracking

Physical plant maintenance logs and HVAC records

Fire drill records for past 12 months (all shifts)

Restraint use logs and less restrictive alternatives

Grievance/complaint logs and resolutions

💊

Nursing Department Checks

DON verifies before and during survey

Medication cart audits complete — all controlled substances reconciled, no expired meds

Critical

All residents' wound assessments documented within the last 7 days with photos where applicable

Critical

Fall risk assessments current — any fall in past 30 days has updated prevention plan

Catheter and tube feeding logs current for all applicable residents

All nurses are in proper uniform with visible name badges showing credentials

Nurse call system tested — all call lights functional

🏥

Environment of Care Walkthrough

Complete a full walk before surveyors do

All hallways clear of equipment obstructing exit paths

Exit signs illuminated on all stairwells and exits

Fire extinguishers inspected and current tags visible

Dining room clean, tables sanitized, HACCP logs current

Resident rooms odor-free — linens clean, no soiled laundry visible

Hand hygiene stations stocked on every unit (foam/gel dispensers)

Isolation rooms properly signed and PPE stocked outside doors

Sharps containers — not overflowing, properly labeled

🍽️

Dietary & Infection Control

High-priority F-tag areas

Kitchen temperature logs current — all coolers, freezers, and hot-holding within range Cooler: 34–40°F • Freezer: 0°F or below • Hot hold: 140°F or above

Critical

Dietary staff wearing gloves and hair restraints during all food prep

All special diets are labeled correctly on trays at meal service Thickened liquids, pureed, diabetic, renal, texture-modified

Critical

Infection surveillance report current — last 30 days reviewed and trended

Antibiotic stewardship documentation available — all antibiotic prescriptions tracked

👥

Staff Guidance — What to Tell Your Team

Brief all staff before survey begins

Answer questions honestly and directly — don't guess or volunteer extra information

Critical

If you don't know the answer, say "I'll find out" — never make something up

Critical

Follow your normal routines — don't change what you do because surveyors are watching

Notify DON immediately if a surveyor raises a concern or asks to see a specific record

Resident rights conversations — all staff know residents can speak privately with surveyors

Survey Day Sign-Off

DON Signature

Administrator Signature

Date / Time Completed