This form may be printed out so that you can make photocopies and use them
for each nursing home facility you check out. You may also choose to check with
the local Ombudsman in your area for confirmation on the facility. They can give
you the information you need on the most recent State inspection, the history of
the home' s complaints and their problems. Contact your local office on aging
for the phone number of your local ombudsman program. Through proper research
and comparisons, you will gain the necessary information to make informed
decisions on choosing a nursing home for your loved one.
City & Postal Code:
Name of Admissions Contact:
Name of Social Worker:
Dates Visited and Times:
Please rate the following questions on a scale of:
- 0 (unacceptable)
- 1 (below average)
- 2 (average)
- 3 (above average)
- 4 (above average)
- 5 (excellent)
Question to Consider
(Spaces are left in between the questions so that you may enter additional
- Is it near to your home?
- What is the accessibility of transportation?
- Is there ample parking space for visitors?
- Is the facility near a bus line?
- What are the visiting hours?
- How do they fit into your schedule?
- What kinds of activities are provided for the residents?
- Are community volunteers encouraged?
- Do they provide a general exercise program based on the patient's ability
- What types of exercise programs are available?
- Are they customizable to the patient's need?
- Are there programs offered away from the facility?
- Is there an extra fee for these programs?
- How is transportation, etc., handled?
- Is there a library or bookmobile available?
- Are there audio cassettes and special books for the visually impaired or
for those who have hearing problems?
- Are there intergenerational activities available and on what basis?
- What types of activity rooms are available for recreation?
- Can family members reserve rooms for private parties or meetings?
- Are there safe areas and gardens for walking and sitting outside?
- What is the physical layout of the facility like?
- Is it attractive?
- Is it well organized?
- Is it designed for the privacy needs of the patient?
- What are the ratios of patients to staff?
- Is the staff welcoming and responsive?
- What is the turnover rate for nurses and assistants?
- Is the level of hygiene maintained-the cleanliness of rooms and
- What is the quality of food like?
- Are the foods nutritious, and geared towards the patient's individual
- Is there fresh drinking water provided in the dining room, in the
residents' rooms and throughout the facility?
- Is assistance available if the patient needs to be fed?
- How is the dining room staffed?
- Are sitting arrangements flexible or are the residents assigned
- Can family members be present during meal times?
- Can family members purchase meals?
- Are snacks and proper foods available in between meals?
- Can residents choose their own menu?
- Is the kitchen clean?
- Are dishes, pots and pans clean?
- Are there bugs?
- What are the resident's rooms like?
- How are they furnished?
- Are they warm and comforting?
- Are there enough blankets and pillows?
- Can you bring in your own bed and furnishings?
- Is there storage for the patient's belongings?
- Can personal items be brought in to create an environment that is
comfortable for them?
- Are these personal items safe?
- How is the theft of personal possessions handled?
- Does the room have an emergency system to call for help?
- Is it working properly?
- Does each room have it's own bathroom and is it clean?
- Does it have the proper hand rails, grab bars and accessories your loved
one will need?
- If patients share rooms with another resident, how are problems
- How accessible are bathrooms outside the patient's own room?
- Is there a phone in the patient's room or nearby for personal use?
- Can those with wheelchairs reach the phone?
- Is there a television and radio in the room if the patient is
- What if the patient prefers to just watch TV or listen to the radio on
their own in the comfort of their room?
- Are personal services available i.e., hair cutting, washing and
- How are ingoing and outgoing personal mail services delivered?
- Are postage services for mailing available?
- Who is responsible for shopping for the personal needs of the
- Are pets allowed and how is this handled if they are?
- How is cash handled for the resident's incidental needs?
- Are all entrances, exits, rooms, and hallways and elevators wheelchair
accessible, and walker accessible and does the width meets the needs of the
patient's means for getting around?
- Is smoking regulated?
- Are exits marked and not blocked?
- Are the floors slippery?
- Are heating and cooling systems adequate and working properly?
- Does the resident have individual control of the heating and cooling
systems in their room?
- Are floors, sidewalks and ramps smooth to prevent tripping and
- Are the grounds well lit?
- Are members of the staff present while residents are outside?
- What special considerations are taken for the residents with memory
problems and wandering issues in the outside areas?
- How frequent are linens changed?
- How are resident's personal laundry needs handled?
- How does the facility involve the family?
- Is there professional support one on one or are there support groups for
the residents and the families?
- Do outside agencies sponsor support groups: i.e., Alzheimer's Association,
Stroke and Parkinson’s?
- How are the resident's spiritual and religious needs met?
- Are there periodic meetings scheduled between the care team and the family
- How often are they?
- How are family members informed of their loved one's status and how
If your loved one has Alzheimer's observe and check out the following:
In terms of Alzheimer's patients, the need for placement will require that
special needs be met daily by the facility. You will want to check out how the
staff interacts with these patients. Many homes now have separate Alzheimer's
units with specialized care. Some may even offer therapeutic programs for the
family members as well. Speak with other residents and their families if
possible, to view things at the home from their perspective.
How knowledgeable and trained are the physicians with Alzheimer's, the
current medical technology etc?
Is the staff trained with the specific dietary, activities and other
problems and needs arising with the patient?
What safety precautions are taken for wandering and hurting
How are they monitored?
Is there confusion and lots of noise in the unit, possibly indicating a
lack of control and supervision on the part of the staff?
How are medications and physical restraints used in behavioral management?
(Remember there are laws governing these restraints. The family must give
permission and certain forms are illegal. No one can be restrained 24 hours a
Observe other residents.
- Do they have bruises on their faces, arms or legs?
- What procedures are used to prevent bed bound patients from developing bed
- Are they dressed properly?
- Are they occupied or are they wandering aimlessly in the halls or left
sitting all alone?
- Do the residents look content, agitated, anxious or unhappy?
- Are there odors in the hallways and communal areas?
- Are smoke detectors and fire extinguishers working and visible?
- Are calls for assistance promptly answered both day and night?
- Is there a physician available for emergencies at all times?
- How often do the physicians visit if they are not present full time?
- Can the resident bring in their own physician?
- What intensive care is provided?
- Are the resident and their family encouraged to participate in developing a
- Are there arrangements through outside services or on site staff for eye,
foot and dental care?
- Are pharmaceutical services handled by a licensed pharmacist?
- Are residents required to carry health insurance?
- Who monitors the dispensing of medications and how is it done?
- Were and what is the nearest hospital?
- Will the home take the patient to the hospital from the facility if
- Will the hospital be able to provide the care that your loved one might
- Is there a family council that meets to handle complaints?
- What types of admission plans are available?
- Single rooms?
- Shared rooms? Is there a waiting list?
- Is there an admissions fee in addition to the regular monthly
- Does the facility accept benefits from Medicare, Medicaid and the Veterans
- What costs are covered by the resident's insurance and what is not?
- What are all the financial costs involved?
- Is the fee daily or monthly and how much is it?
- How are extra needs met?
- What payment options are available?
- What is and is not included in the monthly costs?
- What services are available for extra charges?
- What is the policy regarding daily or monthly rate increases?
- When was the last one?
- What was the last increase?
- How much notice is given regarding an increase and how are they
- Under what conditions are refunds made available to the resident?
- How much notice is needed?
- How long does the home hold a room if a resident needs
- How often are the families informed of the status of the resident?
- Will our loved one need their own aid or nurse 24-hours within the facility
in addition to the home's staff?
- What grounds are cause for the contract to be canceled?
- Does the full time staff include an administrator, a director of nursing, a
social worker, a dietician or nutritionist, and an activities director?
- How are volunteers screened?
- Have staff and volunteers undergone specific training?
- What type?
- How are the workers and volunteers supervised?
Things I Want To Know More About:
- Visit all facilities unannounced. Try to do this when there aren't
- Use the services of an ombudsman. (An ombudsman is an advocate for the
residents). They can find out about past complaints and lawsuits against the
- Do a complete background check on the facility: i.e., ownership,
management, financial stability, and staff qualifications. You can check with
the Chamber of Commerce, the Better Business Bureau and your state's department
- Make sure the facility has complied with all state licensing and
- Get a copy of the last inspection report for the facility.
- Get written copies of all oral agreements or promises.
- Request a copy of the resident's bill of rights. Under the Federal law,
all nursing homes must have a written description of the rights of the residents
and it must be made available to the resident or family member who requests it.
- Meet with the administrator to ask important questions you may have.