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: _____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
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 q
yes q
no understand how to qualify and apply for Medicaid benefits?
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: _____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
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 q
yes q
no
nurse on duty 24
hours a day?
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 q yes q
no
and responsibilities?
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: _____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
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: _____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Resident Rooms
Are resident bedrooms
clean and pleasant? q yes q no
Can residents bring personal items from home (i.e. - a rocking
chair, q
yes q
no
pictures, comforter, etc.)
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 q yes q
no
so clothes are not lost or misplaced?
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 q yes q
no
report to suggest concern in caregiving?
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 q yes q
no
maintenance?
COMMENTS: _____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
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 q yes q
no
the resident (if able) and family member or guardian?
COMMENTS: _____________________________________________________________
_____________________________________________________________
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