|
|
YES |
NO |
COMMENTS |
|
RESIDENTS |
|
|
|
|
Dressed and well cared for |
□ |
□ |
|
|
Involved in activities |
□ |
□ |
|
|
Clean-shaven, hair brushed |
□ |
□ |
|
|
Talking amongst themselves |
□ |
□ |
|
|
Up and moving |
□ |
□ |
|
|
Residents you are licensed to serve |
□ |
□ |
|
|
Level of care |
□ |
□ |
|
|
Help residents maintain abilities (toilet, dress, eat) |
□ |
□ |
|
|
Schedule for staff to check on residents |
□ |
□ |
|
|
Written development plan produced |
□ |
□ |
|
|
Staff training to deal with aggressive individuals |
□ |
□ |
|
|
LIVING SPACES |
|
|
|
|
Size of facility |
□ |
□ |
|
|
Is facility licensed to provide care |
□ |
□ |
|
|
Disclosure Statement |
□ |
□ |
|
|
Basic Fee |
□ |
□ |
|
|
Service & costs available for additional charge |
□ |
□ |
|
|
Initial payment required |
□ |
□ |
|
|
If my needs change, are services available & what? |
□ |
□ |
|
|
Clean, well-kept, free from unpleasant odors |
□ |
□ |
|
|
Temperature comfortable |
□ |
□ |
|
|
Residents allowed to decorate own room |
□ |
□ |
|
|
Possessions kept secure |
□ |
□ |
|
|
Furnishings attractive |
□ |
□ |
|
|
Does the facility meet your requirements |
□ |
□ |
|
|
Do the residents appear happy |
□ |
□ |
|
|
STAFF |
|
|
|
|
Staff relationship friendly with residents |
□ |
□ |
|
|
Staff members in sight |
□ |
□ |
|
|
Name tags on staff |
□ |
□ |
|
|
Staff friendly to you |
□ |
□ |
|
|
Full time RN in nursing home at all times |
□ |
□ |
|
|
Continuing education performed |
□ |
□ |
|
|
Licensed doctor on staff |
□ |
□ |
|
|
Administrator open to questions |
□ |
□ |
|
|
Health monitoring checks |
□ |
□ |
|
|
Safeguards in place so I receive my medications |
□ |
□ |
|
|
Am I allowed to self-medicate |
□ |
□ |
|
|
Observe staff at varying times |
□ |
□ |
|
|
SAFETY |
|
|
|
|
Emergency exits, well-marked, unobstructed |
□ |
□ |
|
|
Lobby and hallway clean |
□ |
□ |
|
|
|
YES |
NO |
COMMENTS |
|
Non-slip surfaces / grab bars in restrooms |
□ |
□ |
|
|
Call button within easy access |
□ |
□ |
|
|
Fire drills |
□ |
□ |
|
|
Training for staff in case of emergencies |
□ |
□ |
|
|
Type of emergencies |
□ |
□ |
|
|
State inspected and when |
□ |
□ |
|
|
Any violations |
□ |
□ |
|
|
Submit plan of correction |
□ |
□ |
|
|
Review plan of correction |
□ |
□ |
|
|
FOOD |
|
|
|
|
Choice of food , menu available, special diets |
□ |
□ |
|
|
Snacks available and/or can be brought into home |
□ |
□ |
|
|
If I miss a meal, are other meals available |
□ |
□ |
|
|
ACTIVITIES / SERVICES |
|
|
|
|
Pharmacy deliver medications |
□ |
□ |
|
|
Can I continue to use my pharmacy |
□ |
□ |
|
|
Physical therapy program |
□ |
□ |
|
|
Social worker on staff – what training |
□ |
□ |
|
|
Active volunteer program |
□ |
□ |
|
|
Outdoor areas |
□ |
□ |
|
|
Organized field trips / activities |
□ |
□ |
|
|
Private areas available to meet with family |
□ |
□ |
|
|
Provides policy on pets |
□ |
□ |
|
|
Provides policy on visitors |
□ |
□ |
|
|
How often will my room be cleaned |
□ |
□ |
|
|
How often will my linens be cleaned |
□ |
□ |
|
|
Provider does my personal laundry |
□ |
□ |
|
|
Are washing machines available |
□ |
□ |
|
|
DISCHARGE |
|
|
|
|
Reasons for discharge |
□ |
□ |
|
|
Internal appeal process |
□ |
□ |
|
|
Notice given & how many days notice is given |
□ |
□ |
|
|
Assistance available, if proceeding with discharge |
□ |
□ |
|
|
SPECIAL CARE / DEMENTIA |
|
|
|
|
Staff training |
□ |
□ |
|
|
Staff to resident ration |
□ |
□ |
|
|
Policy on restraints |
□ |
□ |
|
|
Difference between this unit and rest of facility |
□ |
□ |
|
|
|
|
|
|
OTHER COMMENTS |
|
|
|
|
|
|
|
|
|
|
|
|
|
[1] Note: This document is meant for the clients of The Law Offices of Jerold E. Rothkoff. Before acting on any information presented here, you are strongly urged to consult with an attorney who is competent in this area of the law.