Nursing Home Evaluation Form

Name of Nursing Home:

Date Visited:

The Building and Surroundings
Poor  ===  Excellent      1 =======  5

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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