CMS 802 Form PDF Details

The CMS 802 form is an official care matrix from the Centers for Medicare & Medicaid Services (CMS). Skilled nursing facilities and long-term care homes use it to track resident care needs.

The form covers two resident groups. The first group is newly admitted residents within the last 30 days who are still in the facility. The second group is all other current residents.

Staff who know each resident best complete the CMS 802. The matrix documents data across 20 care categories. These include Alzheimer's disease and dementia diagnoses, insulin and anticoagulant use, and antibiotic therapy. The form also tracks pressure ulcers, weight loss, physical restraints, falls, dialysis treatment, hospice care, palliative care, tracheostomy care, and infectious disease management.

The completed CMS 802 matrix helps state survey agencies evaluate care quality during inspections. It captures a snapshot of resident needs at a specific point in time. Accuracy is critical because the data supports care planning and regulatory compliance.

Official instructions for the CMS 802 are published on the Centers for Medicare & Medicaid Services website.

Related forms include the CMS 671 form for long-term care facility information and the resident assessment form. For Medicare enrollment, you may also need a Medicare consent form or the CMS 40B form.

QuestionAnswer
Form NameCMS 802 Form
Form Length2 pages
Fillable?Yes
Fillable fields0
Avg. time to fill out5 min
Other namesCMS 802 matrix, CMS-802 form, resident roster, cms802, CMS 802 instructions, fillable CMS 802

How to Edit Cms 802 Online for Free

How to Fill Out the CMS 802 Form Online

Use our free PDF editor to complete the CMS 802 form in a few steps.

Step 1: Click "Get form here" to open the CMS 802 in the editor.

Step 2: Use the top toolbar to add text, checkmarks, and signatures to the resident matrix fields.

Enter all required resident data in the CMS fields as shown below.

example of gaps in cms 802 form

Check each of the 20 care categories. Make sure all entries are accurate and complete.

part 2 to filling out cms 802 form

Step 3: Click "Done" to finish. Download the completed CMS 802 as a PDF or send it by email.

Step 4: Print extra copies for your facility records. Keep them on file for state survey reviews.

Looking for related forms? Try the CMS 671 form or the CMS 1763 form.

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