Residents
YES
NO
Notes
Up and out of bed at reasonable time      
Appear clean and dressed      
Interacting with staff and each other      
Participating in a regular schedule of activities      
Receiving meals that are ample and attractive      
Eating most of their meals      
Placed in restraints      
Staff
      
Call the residents by name      
Interact with them      
Respond quickly when called for assistance      
Show respect and courtesy to residents      
Sensitive to ethnic cultural differences      
Knock before entering residents room      
Close doors/curtains for privacy when resident needs bathing, changing, or treatment      
Staffing adequate for serving meals in timely manner      
Staffing adequate to assist in bathing, dressing and attending to other resident needs      
Facility
      
Exterior clean and in good repair      
Outside areas are accessible to residents      
Interior clean, good repair, free of odors      
Bedrooms have necessary equipment and residents are able to have personal items      
Residents have areas for private conversation including phone calls      
There is a room set aside for activities conducted by an Activity Director      
The home has handrails and grab bars in hallway      
Can two wheelchairs pass each other in hallway      
Is there adequate lighting throughout the home      
Do residents have call buttons readily available      
Do all exits have door alarms      
Adequate smoke alarms and detectors      
Is there an emergency lighting system      
Are warning signs displayed on wet floors      
Is the current state facility license displayed      
Is the current administrators license displayed      
Is there an active residents council      
Are residents rights posted and observed by staff      
Are visiting hours clearly posted      
Is the smoking policy posted      
Is the menu clearly posted and followed      
Is the facility under threat of punitive or proposed punitive action      
Comments Positive
Comments Negative