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1. Do the residents appear neat,clean and odor free? 0 The facility was clean; residents were up and <br /> dressed.A resident stated that the bed linens are <br /> changed weekly with clean linens, and additionally <br /> yes as needed. Observations during the facility visit <br /> confirmed that the overall facility and the rooms of <br /> the residents we visited were clean, clutter-free, <br /> well-maintained, and had no noticeable odor <br /> 2. Did residents say they receive assistance with personal care <br /> activities? Ex. brushing their teeth, combing their hair, inserting yes <br /> dentures or cleaning their eyeglasses? <br /> 3. Did you see or hear residents being encouraged to participate in n/a <br /> their care by staff members? <br /> 4. Were residents interacting with staff,other residents&visitors? yes <br /> 5. Did staff respond to or interact with residents who had difficulty <br /> communicating or making their needs known verbally? yes <br /> 6. Did you observe restraints in use? no No restraint facility <br /> 7. If so, did Vou ask staff about the facility's restraintpolicies? n/a <br /> Resident Living Accommodations Yes/No/NA Comments/Other Observations <br /> 8. Did residents describe their living environment as homelike? n/a Staff mentioned they do not wear name badges as <br /> it is a home like environment. <br /> 9. Did you notice unpleasant odors in commonly used areas? no <br /> 10. Did you see items that could cause harm or be hazardous? no <br /> 11. Did residents feel their living areas were too noisy? no <br /> 12. Does the facility accommodate smokers? no <br /> Where? ❑ Outside only❑ Inside only❑ Both Inside/Outside <br /> 13. Were residents able to reach their call bells with ease? yes Staff monitor residents frequently. <br /> 14. Did staff answer call bells in a timely&courteous manner? Staff check on residents frequently. <br /> If no, did you share this with the administrative staff? n/a <br /> Resident • • Observations <br /> 15. Were residents asked their preferences or opinions about the No People come in twice a week to do activities with <br /> activities planned for them at the facility? residents. One resident mentioned that she <br /> wished there were more activities. <br /> 16. Do residents have the opportunity to purchase personal items of yes <br /> their choice using their monthly needs funds? <br /> Can residents access their monthly needs funds at their yes <br /> convenience? <br /> 17. Are residents asked their preferences about meal/snack choices? yes Residents were positive about the quality of the <br /> Are they given a choice about where they prefer to dine? yes food. <br /> 18. Do residents have privacy in making and receiving hone calls? yes <br /> 19. Is there evidence of community involvement from other civic, yes <br /> volunteer or religiousgroups? <br /> 20. Does the facility have a Resident's Council? n/a <br /> Family Council? no <br /> Areas of • • <br /> /NA Exit Summary <br /> Staff concern for residents was demonstrated by <br /> Exit summary: The facility was immaculate.A Hospice nurse was visiting caring interactions. Those who were not napping <br /> several residents during our visit. One resident mentioned that she would were together in the living room. One family <br /> like more showers; staff mentioned they give regular bed baths, and showers member expressed great appreciation for the care <br /> a few times a week. given to her husband. <br /> This Document is PUBLIC RECORD.Do not identify any Resident(s)by name or inference on this form. <br />