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II.
Nursing Home Evaluation Record your observations for each question by circling a number from one to five. (If a question is unimportant to you or doesn't apply to your loved one, leave the evaluation area for that question blank.) Then total all blanks you checked. Your ratings will help you compare nursing homes and choose the best one for your situation. But, don't rely simply on the numbers. Ask to speak to family members of other residents. Also, contact the local or state ombudsman for information about the nursing home and get a copy of the facility's state inspection report from the nursing home, the agency that licenses (or certifies) nursing homes or the ombudsman. Please note that we had trouble formatting this form for the web. You may prefer to use our free printed version that is available by clicking here. Nursing Home Evaluation Form Name of Nursing Home: Date Visited: The Building and Surroundings1 is Poor===5 is Excellent What is your first impression of the facility? 1 2 3 4 5 What is the condition of the facility's exterior paint, gutters and trim? 1 2 3 4 5 Are the grounds pleasant and well-kept? 1 2 3 4 5 Do you like the view from residents' rooms and other windows? 1 2 3 4 5 Do residents with Alzheimer's disease live in a separate Alzheimer's unit? 1 2 3 4 5 Does the nursing home provide a secure outdoor area? 1 2 3 4 5 Is there a secure area where a resident with Alzheimer's disease can safely wander on walking paths? 1 2 3 4 5 Are there appropriate areas for physical therapy and occupational therapy? 1 2 3 4 5 Are facilities for barber or beauty salon services available? 1 2 3 4 5 Is there a well-ventilated room for smokers? 1 2 3 4 5 What is your impression of general cleanliness throughout the facility? 1 2 3 4 5 Does the facility smell clean? 1 2 3 4 5 Is there enough space in resident rooms and common areas for the number of residents? 1 2 3 4 5 How noisy are hallways and common areas? 1 2 3 4 5 Is the dining area clean and pleasant? 1 2 3 4 5 Is there room at and between tables for both residents and aides for those who need assistance with meals? 1 2 3 4 5 Are common areas like lounges and activity rooms in use? 1 2 3 4 5 Are residents allowed to bring pieces of furniture and other personal items to decorate their rooms? 1 2 3 4 5 The
Staff, Policies and Practices Does the administrator know residents by name and speak to them in a pleasant, friendly way? 1 2 3 4 5 Do staff and residents communicate with cheerful, respectful attitudes? 1 2 3 4 5 Do staff and administration seem to work well with each other in a spirit of cooperation? 1 2 3 4 5 Do residents get permanent assignment of staff? 1 2 3 4 5 Do nursing assistants participate in the resident's care planning process? 1 2 3 4 5 How good is the nursing home's record for employee retention? 1 2 3 4 5 Does a state ombudsman visit the nursing home on a regular basis? 1 2 3 4 5 How likely is an increase in private pay rates? 1 2 3 4 5 Are there any additional charges not included in the daily or monthly rate? 1 2 3 4 5 Residents'
Concerns What method is used in selecting roommates? 1 2 3 4 5 What is a typical day like? 1 2 3 4 5 Can residents choose what time to go to bed and wake up? 1 2 3 4 5 Are meaningful activities available that are appropriate for residents? 1 2 3 4 5 If activities are in progress, what is the level of resident participation? 1 2 3 4 5 Can residents continue to participate in interests like gardening or contact with pets? 1 2 3 4 5 Does the nursing home provide transportation for community outings and activities? 1 2 3 4 5 Is a van or bus with wheel chair access available? 1 2 3 4 5 Do residents on Medicaid get mental health services or occupational, speech or physical therapies if needed? 1 2 3 4 5 What is your impression of the general cleanliness and grooming of residents? 1 2 3 4 5 How are decisions about method and frequency of bathing made? 1 2 3 4 5 How do residents get their clothes laundered? 1 2 3 4 5 What happens when clothing or other items are missing? 1 2 3 4 5 Are meals appetizing and served promptly at mealtime? 1 2 3 4 5 Are snacks available between meals? 1 2 3 4 5 If residents call out for help or use a call light, do they get prompt, appropriate responses? 1 2 3 4 5 Does each resident have the same nursing assistant(s) most of the time? 1 2 3 4 5 How does a resident with problems voice a complaint? 1 2 3 4 5 Do residents who are able to participate in care plan meetings? 1 2 3 4 5 Does the nursing home have an effective resident council? 1 2 3 4 5 Family
Considerations How convenient is the nursing home's location to family members who may want to visit the resident? 1 2 3 4 5 Are there areas other than the resident's room where family members can visit? 1 2 3 4 5 Does the facility have safe, well-lighted, convenient parking? 1 2 3 4 5 Are hotels/motels nearby for out-of-town family members? 1 2 3 4 5 Are area restaurants suitable for taking residents out for a meal with family members? 1 2 3 4 5 How convenient will care planning conferences be for interested family members? 1 2 3 4 5 Is an effective family council in place? 1 2 3 4 5 Can family/staff meetings be scheduled to discuss and work out any problems that may arise? 1 2 3 4 5 Can residents choose what time to go to bed and wake up? 1 2 3 4 5 Are meaningful activities available that are appropriate for residents? 1 2 3 4 5 Total Score:
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Legal
Disclaimer Attorneys Judith
Sterling and Michelle Tucker are both CPAs and licensed attorneys. They
are the first two attorneys in Hawaii to be certified by the American
Bar Association (ABA) accredited Estate Law Specialist Board, Inc.,
as Estate Planning Law Specialists, and are so certified by the Supreme
Court of Hawaii. The Supreme Court of Hawaii grants Hawaii certification
only to lawyers in good standing who have successfully completed a specialty
program accredited by the ABA. |
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