Medicaid Certified?

Yes

No

Medicare Certified?

Yes

No

Admitting New Residents?

Yes

No

Admitting Medicare-Medicaid Patients?

Yes

No

Convenient Location?

Yes

No

Is home capable of meeting your special care needs?

Yes

No

1. Are residents treated respectfully by staff at all times?

1   2   3   4   5   6   7   8   9   10

2. Are residents dressed appropriately and well-groomed?

1   2   3   4   5   6   7   8   9   10

3. Does staff make an effort to meet the needs of each resident?

1   2   3   4   5   6   7   8   9   10

4. Are there a variety of activities to meet the needs of residents?

1   2   3   4   5   6   7   8   9   10

5. Is the food attractive and tasty? (Sample a meal if possible.)

1   2   3   4   5   6   7   8   9   10

6. Are resident rooms decorated with personal articles?

1   2   3   4   5   6   7   8   9   10

7. Is the environment homelike?

1   2   3   4   5   6   7   8   9   10

8. Do common areas and resident rooms contain comfortable furniture?

1   2   3   4   5   6   7   8   9   10

9. Does the facility have a family and residents' council?

1   2   3   4   5   6   7   8   9   10

10. Does the facility have contact with outside groups of volunteers?

1   2   3   4   5   6   7   8   9   10

11. Does staff encourage residents to act independently?

1   2   3   4   5   6   7   8   9   10

12. Does facility staff respond quickly to calls for assistance?

1   2   3   4   5   6   7   8   9   10

13. Are residents and family involved in resident care planning?

1   2   3   4   5   6   7   8   9   10

14. Does the home offer appropriate therapies (physical, speech, etc.)?

1   2   3   4   5   6   7   8   9   10

15. Does the nursing home have an arrangement with a nearby hospital?

1   2   3   4   5   6   7   8   9   10

16. Are there enough staff to appropriately provide care to residents?

1   2   3   4   5   6   7   8   9   10

17. Are there handrails in the hallways and grab bars in bathrooms?

1   2   3   4   5   6   7   8   9   10

18. Is the inside of the home in good repair and exits clearly marked?

1   2   3   4   5   6   7   8   9   10

19. Are spills and other accidents cleaned up quickly?

1   2   3   4   5   6   7   8   9   10

20. Are the hallways free of clutter and well-lighted?

1   2   3   4   5   6   7   8   9   10

21. Does the home have outdoor areas for resident use?

1   2   3   4   5   6   7   8   9   10

22. Does the home provide an updated list of references?

1   2   3   4   5   6   7   8   9   10

23. Are the latest survey reports and lists or resident rights posted?

1   2   3   4   5   6   7   8   9   10

24. ___________________________________________

1   2   3   4   5   6   7   8   9   10

25. ___________________________________________

1   2   3   4   5   6   7   8   9   10