| General
Nursing Home Information |
Yes
|
No
|
| Medicare
certified |
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|
| Medicaid
certified |
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|
| Skilled
Nursing Facility |
|
|
| Intermediate
Care Facility |
|
|
| Special
Care Unit available |
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| If
the home offers more that one level of care, may a resident transfer
between levels of care?
|
|
|
| If
the answer is yes, can the resident keep the same room? |
|
|
| If
the home is not Medicaid certified, are residents required to move when
Medicare or the residents private money runs out? |
|
|
| Accepting
new patients |
|
|
|
Waiting period for admission |
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|
| Licensed
home |
|
|
| Licensed
administrator |
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|
Background checks conducted on all staff (both in NC and US?) |
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| Abuse
prevention training provided for staff |
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| Policies
and procedures are in place to safeguard resident possessions. |
|
|
| Continuing
education is provided for all staff. |
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|
| Is
the home appealing on the outside? |
|
|
| Does
the home seem appealing when you go inside? |
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|
| Is
the home convenient to family and friends? |
|
|
| Does
the home have a good reputation in the community? |
|
|
| Quality
of Life |
Yes
|
No
|
| Residents
can make choices about their daily routine (when to go to bed, when
to get up, when to bathe, when to eat, etc.) |
|
|
| The
interaction between staff and patient is warm and respectful. |
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| Easy
to visit for friends and family |
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| Meets
your cultural, religious, or language needs |
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|
| Odor
free |
|
|
| Clean
|
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| Well-lighted |
|
|
| Comfortable
temperatures |
|
|
| Overall,
the facility is quiet |
|
|
| Outdoor
areas for resident use are available. |
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|
| Resident
Rights are prominently posted. |
|
|
| Generally,
residents seem happy and well cared for. |
|
|
| Staff
know residents by name |
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|
| Residents
are involved in a variety of activities |
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|
| Outside
groups are encouraged to visit and/or provide programs |
|
|
| The
home works to provide suitable roommate matches |
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|
| Phone
service is available 24 hours per day |
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|
| The
home has, and follows, a program to restrict the use of physical restraints
to medically necessary situations as identified by the physician. |
|
|
| Is
it easy for wheelchair bound residents to move around the facility? |
|
|
| Are
there private areas for the resident to be able to visit with family
and friends? |
|
|
| Are
personal items allowed in the rooms? |
|
|
| Is
there any safe, secure place for personal possessions of value? |
|
|
| Is
there a varied program of recreational, cultural, and intellectual
activities for residents? |
|
|
| Are
activities available for those confined to their rooms or those who
may be limited from participation in some way?
|
|
|
| Are
married couples allowed to share a room? |
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| Do
all resident rooms have a window to the outside? |
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|
|
Quality of Care |
Yes
|
No |
| The
facility corrected any Quality of Care deficiencies that were in the
State inspection report. |
|
|
| Residents
may continue to see their personal physician. |
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|
| Residents
are clean. |
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| Residents
are appropriately dressed for time of day and year. |
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| Residents
are well-groomed. |
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| Staff
responds quickly to calls for help or assistance. |
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| Residents
have the same caregivers on a daily basis. |
|
|
| There
are enough staff at night, on weekends, or holidays to care for each
resident. |
|
|
| The
home has an arrangement for emergency situations with a nearby hospital
or another like facility. |
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| The
family and resident councils are independent from the nursing homes
management. |
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| Care
plan meetings are held at times that are easy for residents and their
family members to attend.
|
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| Care
plans are updated regularly. |
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| Confidentiality
of medical records is assured |
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| The
home offers restorative programs such as physical therapy, occupational
therapy, speech therapy, etc. |
|
|
| Does
the home have an arrangement with an outside dental service? |
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| Does
the home have arrangements with local hospitals for quick transfer
of patients in an emergency?
|
|
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| Will
the home take responsibility for ensuring that appointments with health
care providers are met?
|
|
|
| Nutrition
and Hydration |
Yes
|
No |
| The
home corrected any deficiencies in these areas that were on the last
survey report. |
|
|
| There
are enough staff to assist each resident who requires help with eating.
|
|
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| Meals
are served at appropriate times. |
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| The
food smells and looks good. |
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| Food
portions appear appropriate. |
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| The
food selections appear to be nutritionally balanced. |
|
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| Residents
are offered choices of food at mealtimes. |
|
|
| Residents
weight is routinely monitored. |
|
|
| Water
pitchers and glasses are available in each room. |
|
|
| Staff
encourages residents to drink if they are not able to do so on their
own. |
|
|
| Residents
can select their own mealtimes. |
|
|
| Residents
are not rushed through the meal. |
|
|
| Nutritious
snacks are available during the day and evening. |
|
|
| The
dining room environment encourages residents to relax, socialize,
and enjoy their food. |
|
|
| Is
food delivered to residents who are unable or unwilling to eat in
the dining room? |
|
|
|
Safety
|
Yes
|
No
|
| Handrails
in the hallways |
|
|
| Grab
bars in the bathrooms |
|
|
| Emergency
call bells in each bathroom |
|
|
| Exits
clearly marked |
|
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| Spills
and accidents cleaned up quickly |
|
|
| Hallways
free of clutter |
|
|
| Hallways
well-lighted |
|
|
| Emergency
plan |
|
|
| Enough
staff to implement the plan |
|
|
| Smoke
detectors and sprinklers on every floor and hall |
|
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| Doors
are locked at an appropriate time at night. |
|
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| Visitors
after a certain time at night must check in with staff. |
|
|
| Is
smoking allowed in the facility? |
|
|
| Are
the bathrooms easy for handicapped residents to use safely? |
|
|
| Are
exit doors unlocked from the inside and easily accessible to residents?
|
|
|
| Is
each bed within reach of a call bell? |
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