CHECK ITEMS:
Nursing Needs
Does the resident's
personal physician regularly make rounds to this facility? q
yes q no
Does this facility specialize
in and meet individual nursing needs? q
yes q no
Is there a physical therapy room
if needed? q yes q
no
COMMENTS: _____________________________________________________________
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Costs and Payment Sources
Is the facility
Medicare certified? q yes q
no
Is the facility Medicaid certified?
q yes q no
If Medicaid is going to be a
possible source of payment, do you
understand how to qualify and apply for Medicaid benefits? q
yes q no
If you don't understand, did
you ask the Administrator? q yes q
no
Does the facility accept private
insurance? q yes q
no
Are you aware of what is included
in cost of care, room and board? q yes q
no
Is there a list of separate charges?
q yes q no
COMMENTS: _____________________________________________________________
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Building and Grounds
Is the facility
wheelchair accessible? q yes q
no
Are there grab bars in toilet
and bathing facilities? q yes q
no
Are there handrails on both sides
of the hallway? q yes q
no
Is the hallway wide enough for
two wheelchairs to pass at the same time? q
yes q no
Is there a fire safety system
and automatic emergency lighting? q yes q
no
Are there portable fire extinguishers?
q yes q no
Are exit doors unobstructed and
unlocked from inside and easily accessible? q
yes q no
Are emergency evacuation plans
posted in prominent locations? q yes q
no
Is there a fire station available
to service this facility? q yes q
no
Is the facility as clean as you
set your personal standards? q yes q
no
Is the facility reasonably free
of unpleasant odors? q yes q
no
Is the facility well lighted?
q yes q no
Is the facility convenient for
frequent visits from family and friends? q
yes q no
Is the building licensed for
the level of care being given? q yes q
no
Is there a wanderer monitoring
system? q yes q
no
COMMENTS: _____________________________________________________________
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Staff's Attitude and Staff
Size
Is there quality
resident and staff activity in the facility? q
yes q no
Is staff courteous to residents
and visitors? q yes q
no
Does the staff respond quickly
to calls for assistance from residents? q
yes q no
Are residents well groomed? Do
they appear to be happy? q yes q
no
Does the staff knock before entering
a room? q yes q
no
Is there a Registered Nurse on
duty during the day and a Licensed Practical nurse on duty 24 hours a day? q
yes q no
Does the staff
know residents by name? q yes q
no
Does the Administrator have a
current license? q yes q
no
Does it seem that the CNAs are
familiar with the needs of the residents they care for? q
yes q no
COMMENTS: _____________________________________________________________
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Tell - Tale Signs
Do residents
look to be functioning independently (or with some q
yes q no
staff assistance as needed)?
Does the facility have a posted
written description of resident rights and responsibilities?
q yes q no
Does the facility have a resident
council? (Review Council Minutes) q yes q
no
Are Hotline and area nursing
home ombudsman telephone numbers posted? q
yes q no
Does the social worker appear
to be a resident/family advocate? q yes q
no
COMMENTS: _____________________________________________________________
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Activities and Events
Are residents
involved in activities sponsored by the facility? q
yes q no
Are volunteers involved in facility
activities? q yes q
no
Is there a private place for
residents to meet with family and friends? q
yes q no
Are there wide ranges of activities
that interest residents? q yes q
no
Can residents choose to participate
or not participate in facility activities? q
yes q no
COMMENTS: _____________________________________________________________
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Resident Rooms
Are resident
bedrooms clean and pleasant? q yes q
no
Can residents bring personal
items from home (i.e. - a rocking chair, pictures, comforter, etc.) q
yes q no
Is there a policy for changing
rooms? q yes q
no
Will the bed be held if a short
hospital stay is needed or required? q yes q
no
Is there a charge for holding
the bed? q yes q
no
Can the resident wear his/her
own clothes? q yes q
no
Does the facility provide laundry
services? q yes q
no
Can the family choose to do its
family member's laundry? q yes q
no
If the facility provides laundry
services, are the resident's clothes marked so clothes are not
lost or misplaced? q yes q no
Are rooms well ventilated and
kept at a comfortable temperature? q yes q
no
Are toilet and bathing facilities
accessible? q yes q
no
COMMENTS: _____________________________________________________________
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Meals and Nutrition
Does the food
look and smell appetizing? q yes q
no
Does it taste good? q
yes q no
Is assistance provided in eating,
if needed? q yes q
no
Do meals served match the menu
planned for the day? q yes q
no
Are there meal substitutes offered
to meet the residents preferences? q
yes q no
Are residents interacting with
one another at the dinner table? q yes q
no
Is a choice of snacks available?
q yes q no
COMMENTS: _____________________________________________________________
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Inspection Reports
Is the facility
licensed by the Department of Public Health? q
yes q no
Did you notice any pattern in
the Department of Public Health inspection report to suggest
concern in caregiving? q yes q no
Does the State report show any
patterns regarding concerns in staffing? q
yes q no
4.Does the State report show
any patterns regarding concerns in ground maintenance? q
yes q no
COMMENTS: _____________________________________________________________
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Health and Happiness Check
Are residents
and families involved in developing their own care plans? q
yes q no
Does the facility provide services
for terminally ill? q yes q
no
Are residents able to use their
own physician? q yes q
no
Is there a resident assessment
or care plan designed to meet residents needs? q
yes q no
Are regularly scheduled care
plan meetings being held that actively involve the resident (if
able) and family member or guardian?
q yes q no
COMMENTS: _____________________________________________________________
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