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Name of Nursing
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Date of Visit: |
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Yes
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No
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Comments |
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Basic Information |
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Home is Medicare-certified. |
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Home is Medicaid-certified. |
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Home has the level of care you need (e.g. skilled,
custodial),
and a bed is available. |
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Home has special services if needed in a separate unit (e.g.
dementia, ventilator, or rehabilitation), and a bed is available. |
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Home is located close enough for friends and family to visit. |
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Resident Appearance |
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Residents are clean, appropriately dressed for the season or time of
day, and well groomed. |
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Nursing Home Living
Spaces |
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Home is free from overwhelming unpleasant odors. |
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Home appears clean and well kept. |
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The temperature in the nursing home is comfortable for residents. |
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Home has good lighting. |
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Noise levels in the dining room and other common areas are
comfortable. |
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Smoking is not allowed or may be restricted to certain areas of the
nursing home. |
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Furnishings are sturdy, yet comfortable and attractive. |
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Staff |
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The relationship between the staff and the residents appears to be
warm, polite, and respectful. |
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All staff wear name tags. |
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Staff knock on the door before entering a resident's room and refer
to residents by name. |
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Home offers a training and continuing education program for all
staff. |
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Home does background checks on all staff. |
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The guide on your tour knows the residents by name and is recognized
by them. |
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There is a full-time Registered Nurse (RN) in the nursing home at
all times, other than the Administrator or Director of Nursing. |
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The same team of nurses and
Certified Nursing
Assistants (CNAs)
work with the same resident 4 to 5 days per week. |
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CNAs work with a reasonable number of residents. |
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CNAs are involved in care planning meetings. |
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There is a full-time social worker on staff. |
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There is a licensed doctor on staff. Is he or she there daily? Can
he or she be reached at all times? |
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Home's management team has worked together for at least one year. |
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Residents' Rooms |
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Residents may have personal belongings and/or furniture in their
rooms. |
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Each resident has storage space (closet and drawers) in his or her
room. |
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Each resident has a window in his or her bedroom. |
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Residents have access to a personal telephone and television. |
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Residents have a choice of roommates. |
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Water pitchers can be reached by resident. |
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There are policies and procedures to protect residents’ possessions. |
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Hallways, Stairs,
Lounges, and Bathrooms |
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Exits are clearly marked. |
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There are quiet areas where residents can visit with friends and
family. |
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Home has smoke detectors and sprinklers. |
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All common areas, resident rooms, and doorways are designed for
wheelchair use. |
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There are handrails in the hallways and grab bars in the bathrooms. |
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Menus and Food |
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Residents have a choice of food items at each meal. (Ask if your
favorite foods are served.) |
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Nutritious snacks are available upon request. |
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Staff help residents eat and drink at mealtimes if help is needed. |
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Activities |
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Residents, including those who are unable to leave their rooms, may
choose to take part in a variety of activities. |
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Home has outdoor areas for resident use and staff help residents go
outside. |
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Home has an active volunteer program. |
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Safety and Care |
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Home has an emergency evacuation plan and holds regular fire drills. |
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Residents get preventive care, like a yearly flu shot, to help keep
them healthy. |
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Residents may still see their personal doctors. |
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Home has an arrangement with a nearby hospital for emergencies. |
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Care plan meetings are held at times that are convenient for
residents and family members to attend whenever possible. |
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Home has corrected all deficiencies (failure to meet one or more
Federal or State requirements) on its last state inspection report. |
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