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  • Home
  • Administrator’s Corner
    • Electronic Monitoring
    • Event Management
    • Facility Assessment
    • Guardian Angel Program
    • Illinois Regulatory Compliance
    • Involuntary Transfer and Discharge
    • Medicare Meeting
    • QA Zone Program
    • Reasonable Suspicion of a Crime
    • Resident Background Checks
    • Sample Contracts
    • Survey: POC/Abatement/IDR
  • Admissions
  • Advance Directives
  • Checklists 10/2025
  • Clinical Corner
    • Aggression Management
    • Competency Testing
    • DON Meetings
    • Fitzsimmons NPWT
    • Freeze the Falls
    • Hepatitis and HIV Screening
    • In-Services and Training
    • ISDH – Fall Prevention Presentation and Materials
    • Quality Assurance
    • Restorative
    • Toileting Program
    • Vaccine Administration
    • Wipe Out Wounds
  • Consultant’s Corner
  • Dietary Corner
    • Clinical Medical Therapy
    • Dating and Labeling
    • Emergency Preparedness
    • Forms
    • Meal Service
    • Menu
    • Personnel
    • Rules and Regulation
    • Sanitation
  • Educational Resources
  • Forms
    • Risk Benefit
  • HIM
  • Human Resources
    • Employee Health
    • Facility Orientation Program
    • Fingerprint Background Checks
    • Job Descriptions
    • Preceptor Program
  • JCAHO
    • Audit Forms
    • Competency Testing
    • Education Handouts
    • Emergency Management
    • Environment of Care
    • Hand-off Communication
    • Infection Control Rounds
    • Infection Risk Assessment
    • IV infection
    • Language Interpreter
    • Management Plans
    • Medical Devices
    • Nursing
    • Performance Improvement
  • Maintenance
    • Maintenance Forms
  • MDS/Care Plan
  • OSHA
  • PDPM
  • Pharmacy Policies – MAC Rx
    • DON Handbook
    • General Pharmacy Policies
    • IV Therapy Policy & Procedures
    • Pharmacy Forms
  • Policies and Procedures
    • Administrative Manual
    • Emergency Preparedness Manuals
    • Hot Weather Procedures
    • Medical Director and Attending Physicians
    • Misc Administrative
      • Grievances
    • Nursing Guidelines
      • Admissions, Transfers and Discharge
      • Assessments and Care Planning
      • Behavior, Mood and Cognition
      • Cardiovascular Conditions
      • Diabetic Care
      • Dialysis
        • Hemodialysis
        • Peritoneal Dialysis
      • Documentation
      • Electronic Records
      • Emergency and First Aid
      • End of Life Care
      • Falls and Fall Risk
      • Gastrointestinal Conditions
      • Infection Control
      • Managing Infections
      • Miscellaneous
      • Musculoskeletal Conditions
      • Nutrition and Hydration
      • Orders, Receiving and Transcribing
      • Pain Management
      • Personal Care
      • Personnel and Staffing
      • Positioning and Moving
      • Rehabilitative and Restorative Care
      • Resident Rights and Dignity
      • Resident Safety
      • Respiratory and Pulmonary Conditions
      • Skin and Wound Management
      • Specimen Collection
      • Urinary and Renal Conditions
    • Safety-Hazards-Maintenance
  • Provider/Physician Page
  • QAPI
    • Critical Element Pathways (CEP)
    • Interviews/Observations
  • Regulatory Compliance
    • ACA Section 1557 Grievance Policy and Procedure
    • COMPLINCE AND ETHICS PHYSICIAN/VENDOR
    • Corporate Compliance and Ethics Program
    • HIPAA
    • HITECH Policy and Procedures
  • SMHRF
    • SMHRF Emergency Management
    • SMHRF Job Descriptions
  • Survey
    • MDS 3.0 FOCUSED SURVEY
    • SURVEY PREPAREDNESS
  • The Manors
  • Archive – Reference Only
    • Covid-19 Archive
    • Dietary Corner – Forms
    • Dietary Corner – Sanitation Policies
    • Illinois Licensure Violations
    • OLD General Pharmacy Policies
    • OLD IV Therapy Policy & Procedures – Archived 10/2016
    • Dietary Corner – Additional Policies
    • COVID-19 – Resource Book (Archived)
  • COVID-19
    • Temporary Nurse Aide Training

MDS 3.0 FOCUSED SURVEY

MDS 3 0 Focused Survey  –

Focused Survey Facility Worksheet Template

FOCUSED SURVEY FACILITY WORKSHEET (MDS WORKSHEET #1) COMPLETION INSTRUCTIONS

Surveyor Access Cheat Sheet

Resources

  • CDC Isolation Precautions
  • Chapter 8 Medicare Benefit Policy Manual
  • ECC Online SDS
  • eHealth Data Solutions
  • Illinois Council on Long Term Care
  • Illinois Rules and Regulations
  • INTERACT
  • MDS 3.0 RAI Manual
  • MDS 3.0 Quality Measures User Manual
  • Medicare.gov: Nursing Home Compare
  • National Action Plan for Adverse Drug Event Prevention
  • Nursing Home Care Act
  • Nursing Home Quality Initiative (MDS 3.0)
  • OBRA Regulations
  • Omnicare Omniview
  • QIS Survey Preparation Forms
  • Reimbursement for Nursing Costs for Geriatric Facilities
  • Part 690 – Control Of Communicable Diseases Code

All Pages

  • Administrator's Corner
    • Electronic Monitoring
    • Event Management
    • Facility Assessment
    • Guardian Angel Program
    • Illinois Regulatory Compliance
    • Involuntary Transfer and Discharge
    • Medicare Meeting
    • QA Zone Program
    • Reasonable Suspicion of a Crime
    • Resident Background Checks
    • Sample Contracts
    • Survey: POC/Abatement/IDR
  • Admissions
  • Advance Directives
  • Checklists 10/2025
  • Clinical Corner
    • Aggression Management
    • Competency Testing
    • DON Meetings
    • Fitzsimmons NPWT
    • Freeze the Falls
    • Hepatitis and HIV Screening
    • In-Services and Training
    • ISDH - Fall Prevention Presentation and Materials
    • Quality Assurance
    • Restorative
    • Toileting Program
    • Vaccine Administration
    • Wipe Out Wounds
  • Consultant's Corner
  • Dietary Corner
    • Clinical Medical Therapy
    • Dating and Labeling
    • Emergency Preparedness
    • Forms
    • Meal Service
    • Menu
    • Personnel
    • Rules and Regulation
    • Sanitation
  • Educational Resources
  • Forms
    • Risk Benefit
  • HIM
  • Human Resources
    • Employee Health
    • Facility Orientation Program
    • Fingerprint Background Checks
    • Job Descriptions
    • Preceptor Program
  • JCAHO
    • Audit Forms
    • Competency Testing
    • Education Handouts
    • Emergency Management
    • Environment of Care
    • Hand-off Communication
    • Infection Control Rounds
    • Infection Risk Assessment
    • IV infection
    • Language Interpreter
    • Management Plans
    • Medical Devices
    • Nursing
    • Performance Improvement
  • Maintenance
    • Maintenance Forms
  • MDS/Care Plan
  • OSHA
  • PDPM
  • Pharmacy Policies - MAC Rx
    • DON Handbook
    • General Pharmacy Policies
    • IV Therapy Policy & Procedures
    • Pharmacy Forms
  • Policies and Procedures
    • Administrative Manual
    • Emergency Preparedness Manuals
    • Hot Weather Procedures
    • Medical Director and Attending Physicians
    • Misc Administrative
      • Grievances
    • Nursing Guidelines
      • Admissions, Transfers and Discharge
      • Assessments and Care Planning
      • Behavior, Mood and Cognition
      • Cardiovascular Conditions
      • Diabetic Care
      • Dialysis
        • Hemodialysis
        • Peritoneal Dialysis
      • Documentation
      • Electronic Records
      • Emergency and First Aid
      • End of Life Care
      • Falls and Fall Risk
      • Gastrointestinal Conditions
      • Infection Control
      • Managing Infections
      • Miscellaneous
      • Musculoskeletal Conditions
      • Nutrition and Hydration
      • Orders, Receiving and Transcribing
      • Pain Management
      • Personal Care
      • Personnel and Staffing
      • Positioning and Moving
      • Rehabilitative and Restorative Care
      • Resident Rights and Dignity
      • Resident Safety
      • Respiratory and Pulmonary Conditions
      • Skin and Wound Management
      • Specimen Collection
      • Urinary and Renal Conditions
    • Safety-Hazards-Maintenance
  • Provider/Physician Page
  • QAPI
    • Critical Element Pathways (CEP)
    • Interviews/Observations
  • Regulatory Compliance
    • ACA Section 1557 Grievance Policy and Procedure
    • COMPLINCE AND ETHICS PHYSICIAN/VENDOR
    • Corporate Compliance and Ethics Program
    • HIPAA
    • HITECH Policy and Procedures
  • SMHRF
    • SMHRF Emergency Management
    • SMHRF Job Descriptions
  • Survey
    • MDS 3.0 FOCUSED SURVEY
    • SURVEY PREPAREDNESS
  • The Manors
  • Welcome
  • Archive - Reference Only
    • Covid-19 Archive
    • Dietary Corner - Forms
    • Dietary Corner - Sanitation Policies
    • Illinois Licensure Violations
    • OLD General Pharmacy Policies
    • OLD IV Therapy Policy & Procedures - Archived 10/2016
    • Dietary Corner - Additional Policies
    • COVID-19 - Resource Book (Archived)
  • COVID-19
    • Temporary Nurse Aide Training
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Copyright © 2026 LTC Compliance