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FACILITY FEATURES
�� ���� ���� ���� ���� ���� �� Is the nursing home near a hospital?
���� ���� ���� ���� ���� �� Is the facility conveniently located for family, friends, and physician?
���� ���� ���� ���� ���� �� Does cleanliness meet personal standards throughout the facility?
���� ���� ���� ���� ���� �� Is the facility well lit inside and out?
���� ���� ���� ���� ���� �� Is furniture sturdy, attractive and clean?
���� ���� ���� ���� ���� �� Are there plenty of sitting areas for people to gather?
���� ���� ���� ���� ���� �� Is there an outdoor porch with a sitting area?
���� ���� ���� ���� ���� �� Is the porch secured?
���� ���� ���� ���� ���� �� Is the facility free of unpleasant odors?
���� ���� ���� ���� ���� �� Is the scent of “pleasant” odor too strong? (If so, the facility could be
masking foul odors)
���� ���� ���� ���� ���� �� Are there handrails and grab bars throughout the facility including
patient’s room and bathroom?
���� ���� ���� ���� ���� �� Are exits clearly marked and unobstructed?
���� ���� ���� ���� ���� �� Is there a nurse call button by each bed?
���� ���� ���� ���� ���� �� Is fresh drinking water beside each bed?
���� ���� ���� ���� ���� �� Is there at least one comfortable chair per patient in patient’s room?
���� ���� ���� ���� ���� �� Is there easy access to each bed for a wheelchair?
�� ���� ���� ���� ���� ���� �� Is there an emergency call button in the bathroom?
STAFF
How long have key personnel been at the facility?
____ ____ ____ Administrator/Executive Director?
____ ____ ____ Director of Nursing?
____ ____ ____ Dietary Director?
____ ____ ____ Activities Director?
������������ ������������ ���������� How many RNs or LPNs are on duty? What is the ratio of nurses to
patients?
____ ____ ____ Day?
____ ____ ____ Evening?
____ ____ ____ Night?
������������ ������������ ���������� How many nurse aides are on duty? What is the ratio of nurse aides
to patients?
____ ____ ____ Day?
____ ____ ____ Evening?
____ ____ ____ Night?
���� ���� ���� ���� ���� �� Are common dining areas available? May they sit anywhere?
���� ���� ���� ���� ���� �� Are you greeted by staff as you tour the facility?
���� ���� ���� ���� ���� �� Does staff demeanor seem to be chaotic or stressed?
���� ���� ���� ���� ���� �� Does staff seem to be generally happy?
���� ���� ���� ���� ���� �� Does staff show interest in and affection for individual patients?
���� ���� ���� ���� ���� �� Does staff respond quickly to patient calls for assistance?
���� ���� ���� ���� ���� �� Does staff smile while they are interacting with the patients?
�� ���� ���� ���� ���� ���� �� Does staff respect patient’s dignity and privacy?
���� ���� ���� ���� ���� �� Does staff knock before entering patient’s room?
���� ���� ���� ���� ���� �� Does staff draw bed separation curtain when care is being given?
���� ���� ���� ���� ���� �� When care is being given is the patient’s dignity being respected?
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