Observe Building
Are the following rooms clean and in good repair:

Residents’ rooms?	Yes	No
Bathrooms?	Yes	No
Kitchen?	Yes	No
Lounge/visitor’s area?	Yes	No
Activity room?	Yes	No
Are personal items (e.g., furniture, photos, radios, TVs, etc.) permitted in the rooms?	Yes	No

How many persons live in one room? ________

Does this make a difference to you? Yes   No

Comments:

Observe Staff

Is there an RN and/or LPN on duty?	Yes	No
What is the staff-resident ratio?	______
Are staff members smiling and friendly?	Yes	No
Are staff members neat and clean?	Yes	No
Are staff members visible and available?	Yes	No

Do staff members seem kind and considerate toward:

Residents?	Yes	No
Visitors?	Yes	No
Family members?	Yes	No
Other staff members?	Yes	No

Comments:

Listen

Do the staff speak courteously with the residents?	Yes	No
Do the staff speak to the residents as adults?	Yes	No
Do residents complain about the facility?	Yes	No
Do the staff complain about working conditions?	Yes	No

Comments:

Food

Do residents have a choice in the food served?	Yes	No
Is the dining room convenient, cheerful, and comfortable?	Yes	No
Is food appetizing, adequate, and attractively served?	Yes	No
Are fresh fruits and vegetables served?	Yes	No
Are staff and/or volunteers helping residents who need assistance?	Yes	No
Are snacks served throughout the day and in the evening?	Yes	No
Are meals available for guests?	Yes	No

Comments:

Smell

Is there a strong body or urine odor throughout the building?	Yes	No
Is there a strong deodorant smell?	Yes	No

Comments:

Ask

Are religious services provided?	Yes	No
Is there a residents’ council?	Yes	No
Is there an activities program?	Yes	No
Is recreational therapy provided?	Yes	No
Is physical therapy provided?	Yes	No
Is occupational therapy provided?	Yes	No
Is speech therapy provided?	Yes	No

Are the following professionals on staff:

Medical doctors?	Yes	No
Dentist?	Yes	No
Optometrist?	Yes	No
Podiatrist?	Yes	No
Chaplain?	Yes	No
Social Worker?	Yes	No
Are there other professionals on the staff?	Yes	No

Comments:

Does this facility meet personal interest needs?

Yes

No

Comments:

Money

Is a deposit required?	Yes	No
Are provisions available to handle personal funds?	Yes	No

What other costs are involved:

Drugs and medications?	Yes	No
Beauty salon/barber?	Yes	No
Activity fees?	Yes	No
Laundry?	Yes	No
Snacks?	Yes	No
May a resident stay when his/her own funds have run out?	Yes	No

Comments:

How often does the resident, family member, or guardian receive an itemized accounting of personal funds?

In the event of death, what happens to any unused funds?

3. Additional Comments