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