| CLIENT NAME: |
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| DATE: |
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| FACILITY NAME: |
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| Do you like the facility's location and outward appearance? |
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| Is the facility convenient for frequent visits by family and friends? |
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| Are you welcomed with a warm greeting from the staff? |
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| Does the staff address residents by their names and interact with them during your tour? |
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| Do you notice the residents socializing with each other and do they appear content? |
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| Can you talk with residents about how they like living there and about the staff? |
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| Is the staff appropriately dressed, friendly and outgoing? |
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| Do the staff members treat each other in a professional manner? |
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| Are visits with the residents encouraged and welcome at any time? |
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| What percentage of the rooms/beds is available? |
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| Is there a waiting list? If so, how long do they estimate it will take to be admitted? |
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| Living Area and Accommodations |
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| Is the floor plan well designed and easy to follow? |
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| Are doorways, hallways and rooms accommodating to wheelchairs and walkers? |
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| Are elevators available for those unable to use stairways and handrails to aid in walking? |
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| Are floors of a non-skid material and carpets conducive for safe walking? |
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| Does the residence have good lighting, sprinklers and clearly marked exits? |
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| Is the residence clean, free of odors and appropriately heated/cooled? |
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| What is the facility's means of security if a resident wanders? |
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| Are the common areas in general attractive, comfortable and clean? |
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| Is there an outside courtyard or patio for residents and visitors, and assistance getting there? |
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| Does the residence provide ample security and is there an emergency evacuation plan? |
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| Are private rooms available and/or double occupancy units for sharing with another person? |
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| Does residence have furnished/unfurnished rooms? What is provided or what can they bring? |
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| May they decorate their own rooms? Is there adequate storage space? |
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| Is a 24-hour emergency response system accessible from the unit? |
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| Are bathrooms private with handicapped accommodations for wheelchairs and walkers? |
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| Do all units have a telephone and cable TV and how is billing handled? |
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| Moving In, Contracts, and Finances |
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| What's involved with the moving in/out process? How is the initial needs assessment done? |
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| Does assessment process include the resident, family, facility staff, along with the physician? |
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| Is there a written plan for the care of each resident? |
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| Is there an ongoing process for assessing a resident's need for services and how often are those needs evaluated? |
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| Is there a written statement available of the resident rights and responsibilities? |
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| Is a contractual agreement available that clearly discloses healthcare, accommodations, personal care and supportive services, all fees, and admission and discharge provisions? |
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| What type of insurance is required/accepted? Medicare/Medicaid/Medigap/Long-term care/Private? |
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| What are the specific costs for various levels of care including skilled/unskilled beds? |
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| What additional services and staff are available if the resident's needs change? |
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| When may a contract be terminated and what are the policies for refunds and transfers? Is there an appeals process for dissatisfied residents? |
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| What happens if funds are depleted and full payments can no longer be made? |
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| Is there any government, private or corporate programs available to help cover the costs? |
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| Is there any government, private or corporate programs available to help cover the costs? |
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| Is there a procedure to pay for additional services such as skilled nursing care when the services are needed on a temporary basis? |
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| Do billing, payment and credit policies seem fair and reasonable? |
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| May resident handle his/her own finances with staff assistance if able? Must a family member/outside party be designated? |
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| Health/Personal Care/Services |
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| What type of healthcare and personal care services are available? |
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| What type of healthcare and personal care services are available? |
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| Does the facility have both short and long-term services, such as routine physical and dental/vision examinations as well as skilled nursing? |
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| Can the facility provide a list of available services and are residents and families involved in developing the care plan/service agreement? |
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| Who provides these services/what are their qualifications? |
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| Are physical, occupational, or speech therapy services available onsite? |
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| Who coordinates these services and how are they billed to Medicare/Medicaid or other third party insurance? |
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| Is staff available to provide 24-hour assistance with activities of daily living (ADLs) if needed? ADLs include dressing eating, mobility, hygiene, grooming (bathing, toileting, incontinence) |
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| Does the residence have Alzheimer's programs, or other dementias and other specialized areas? How does staff safely manage residents who might wander? |
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| Is staff available to assist residents who experience memory, orientation, of judgment losses? |
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| How are medical emergencies handled? |
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| Does the residence have a clearly stated procedure for responding to medical emergencies? Is there an arrangement with a nearby hospital? |
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| Are housekeeping, linen service and personal laundry included in the fees, or extra charges? |
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| Does the residence provide transportation to doctors' offices, the hairdresser, shopping and other activities desired by residents and can it be arranged on short notice? |
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| Are pharmacy, barber/beautician and/or physical therapy services offered on-site? |
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| How does staff safely administer, monitor, and assist a resident in taking medicine? |
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| Does the residence's pharmacy provide delivery, consultation and review of medicines? |
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| Does a staff physician visit the resident regularly for medical checkups or can resident his/her have own personal physician? |
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| Social and Recreational |
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| What kinds of group/individual recreational activities are offered and who schedules them? |
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| Is there an organized activities program with a posted daily schedule of events? |
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| Do volunteers and family members come into the residence to participate/conduct programs? |
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| Does the facility schedule trips or go to other events off premises? |
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| Do residents participate in activities outside of the residence in the neighboring community? |
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| Are the resident activity (social) areas appropriate and desirable to the prospective resident? |
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| Are there supplies for social activities/hobbies (games, cards, crafts, computers, gardening)? |
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| Are religious services held on the premises or arrangements made for nearby services? |
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| Are there fitness facilities, as well as regularly scheduled exercise classes? |
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| Does the residence create a sense of community by allowing residents to participate in certain activities or perform simple chores for the group as a whole? |
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| Does facility have pets? Who is responsible for their care? |
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| Staff |
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| Are nursing staff members courteous and friendly to residents and to other staff? |
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| Do nursing staff respond timely to residents requests for assistance such as help getting in and out of bed, dressing and going to the bathroom? |
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| Which nursing staff members are involved in planning the resident's individual care? Are they the same ones who give the care to residents? |
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| Ask questions about staff turnover. Is there frequent turnover among certified nursing assistants (CNAs)? What about turnover for nurses and supervisors, including the Director of Nursing and the Administrator? |
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| What is the nursing staff to resident ratio? How many registered nurses (RNs) and Licensed Practical Nurses (LPNs) are on staff? How many per shift? What is their training/education? |
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| What is the nursing assistant to resident ratio and how many are on staff? How many on each shift? What kind of training do certified nursing assistants (CNAs) receive? |
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| What is history of compliance with staffing ratios? Are there incentives to help with staffing? |
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| How does the nursing home ensure that all staff maintains licensure/certification, receives continuing education, and keeps their knowledge and skills up-to-date? |
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| Food |
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| Does the residence provide three nutritionally balanced meals a day, seven days a week, and how does the menu vary from meal to meal? |
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| Observe meal times. Do all residents who need assistance with eating get help? Does staff give each resident enough time to chew food thoroughly and complete the meal? |
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| What about special diets; does a dietitian plan or approve menus? Are resident's weight routinely monitored? |
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| Are residents involved in menu planning? Can request special foods? Are snacks available? |
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| Does dining room environment encourage residents to relax, socialize, and enjoy their food? |
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| Are water pitchers/glasses accessible in rooms and does staff assist with drinking as needed? |
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| Are common dining areas available? Is tray service available when ill and staff to assist? Are common dining areas available? Is tray service available when ill and staff to assist? |
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| May meals be provided at a time a resident would like or are there set times for meals? |
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| May residents have guests for meals in the dining room for an additional fee? Is there a private dining room for special events and occasions? |
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| Licensure and Certification |
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| Is the facility Medicare certified and/or Medicaid certified? |
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| Is this a skilled nursing facility and is a skilled bed available? |
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| Is the facility accepting new patients? Is there a waiting period for admission? |
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| If the facility is sponsored by a nonprofit organization and managed under contract with a commercial firm, what are the conditions of that contract? |
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| Is there a resident council or organization through which resident/family have a means of voicing their views on the management of the community? |
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| Each state requires the residence to be licensed and/or certified. Does the facility have a current license/certification and is it displayed? |
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| Each state requires the administrator to be licensed/certified. Does she/he have current license/certification? |
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| What reputation does the facility have in the community? How long has it been in business? Is it in good financial health? Does the facility follow generally accepted accounting procedures? |
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| Has the facility corrected any Quality of Care deficiencies in their State inspection report? |
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