Official Federal Forms
Centers For Medicare And Medicaid Services
Last updated: 1/8/2024
Roster-Sample Matrix {CMS-802}
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Description
CMS-802 - MATRIX FOR PROVIDERS. The Matrix is used to identify pertinent care categories for: 1) newly admitted residents in the last 30 days who are still residing in the facility, and 2) all other residents. The facility completes the resident name, resident room number and columns 1–20, which are described in detail below. Blank columns are for Surveyor Use Only. All information entered into the form should be verified by a staff member knowledgeable about the resident population. Information must be reflective of all residents as of the day of survey. www.FormsWorkflow.com
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