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CARE
���� ���� ���� ���� ���� �� Do patients look to be clean and properly groomed?
(Hair combed, shaven, nails trimmed, and manicured, etc)
���� ���� ���� ���� ���� �� Are patients appropriately dressed for time of day, activity, or
weather?
���� ���� ���� ���� ���� �� Does the facility conduct a preliminary evaluation of the resident’s
needs? (A care plan)
���� ���� ���� ���� ���� �� Can patient and family members be present during this evaluation?
____ ____ ____ How often is this care plan evaluation updated?
���� ���� ���� ���� ���� �� Does the home have an Alzheimer’s program?
���� ���� ���� ���� ���� �� Does the facility report periodically in writing to the personal
physician?
���� ���� ���� ���� ���� �� Is there a therapy program available to meet patient’s needs?
���� ���� ���� ���� ���� �� Is the therapy program on site or off premises?
DINING & FOOD
���� ���� ���� ���� ���� �� Is the kitchen area clean including the food storage area?
���� ���� ���� ���� ���� �� Is the dining area well lit and attractive?
���� ���� ���� ���� ���� �� Are personal likes and dislikes taken into consideration?
���� ���� ���� ���� ���� �� Does the dietitian plan a variety of menus for patients on special diets?
�� ���� ���� ���� ���� ���� �� Are snacks available?
�� ���� ���� ���� ���� ���� �� Are foods served at the appropriate temperatures?
�� ���� ���� ���� ���� ���� �� Is food tasty and attractively served?
�� ���� ���� ���� ���� ���� �� Is there enough staff to assist patients who need help with eating?
SOCIAL SERVICES / ACTIVITIES PROGRAM
���� ���� ���� ���� ���� �� Are rooms available for patient activities?
���� ���� ���� ���� ���� �� Is equipment (such as games, easels, yarn, cards, etc.) available?
���� ���� ���� ���� ���� �� Are residents using such equipment?
���� ���� ���� ���� ���� �� Are patient preferences observed?
���� ���� ���� ���� ���� �� Are group & individual activities available? Participation encouraged?
���� ���� ���� ���� ���� �� Are outside trips planned?
���� ���� ���� ���� ���� �� Are arrangements made for patients to worship as they please?
���� ���� ���� ���� ���� �� Is a social worker available to assist residents and families?
LICENSOR / COSTS
���� ���� ���� ���� ���� �� Does the home have a current license? If no, do not use home.
���� ���� ���� ���� ���� �� Does the administrator have a current license? If no, do not use.
���� ���� ���� ���� ���� �� Is the home Medicare and/or Medicaid Certified?
���� ���� ���� ���� ���� �� Are all services covered in the basic daily charge?
���� ���� ���� ���� ���� �� Does the facility have a written description of its services & fees?
���� ���� ���� ���� ���� �� Are advanced payments returned if the patient leaves the home?
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