Name of Nursing Home: ____________________________ Date of Visit: ______________
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Comments |
| Basic Information |
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| Medicare-certified. |
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| Medicaid-certified. |
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| Level of care offered and bed available. |
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| Special services (e.g. dementia, rehab). |
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| Located close to family. |
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| Resident Appearance |
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| Clean, well groomed, appropriately dressed. |
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| Nursing Home Living Spaces |
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| Free from overwhelming unpleasant odors. |
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| Clean and well-kept. |
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| Temperature is comfotable for residents. |
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| Good lighting. |
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| Noise levels comfortable. |
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| Smoking not allowed or restricted. |
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| Staff |
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| Relationship between the staff and the residents appears to be warm, polite, and respectful. |
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| All staff wear name tags. |
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| Staff knock on the door before entering and refer to residents by name. |
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| In-Service training for all staff. |
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| Background checks on all staff. |
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| Full-time Registered Nurse (RN) in the nursing home at all times. |
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| Consistent staff. |
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| CNAs care for a reasonable number of residents. |
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| Full-time social worker on staff. |
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| Licensed doctor on staff. |
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| Nursing home's management team has worked together for at least one year. |
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| Residents' Rooms |
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| Residents may have personal belongings and/or furniture in their rooms. |
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| Sufficient storage space. |
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| Each resident has a window. |
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| Residents have access to phone and T.V. |
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| Residents have a choice of roommates. |
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| Water pitchers accessible. |
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| Policies to protect resident's possessions. |
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| Hallways, Stairs, Lounges, and Bathrooms |
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| Exits are clearly marked. |
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| Quiet areas where residents can visit with friends and family. |
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| Smoke detectors and sprinklers. |
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| Facility designed for wheelchair use. |
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| Handrails in the halls and bathrooms. |
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| Menus and Food |
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Residents have a choice of food items at meals.
(Ask if your favorite foods are served) |
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| Nutritious snacks are available. |
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| Staff assists residents with feeding. |
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| Activities |
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| Variety of activities offered. |
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| Outdoor areas for resident use. |
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| An active volunteer program. |
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| Safety and Care |
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| Emergency plan in place/regular fire drills. |
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| Resident may see personal doctors. |
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| Hospital nearby for emergencies. |
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| Care plan meetings convenient for family. |
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| Corrected all deficiencies on last inspection. |
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