Facility Self-Assessment (Mock Survey) Tool - Nursing Home Help

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GENERAL OBSERVATIONS OF THE FACILITY Tag I Concerns Source * Surveyor Notes (including date/time) *Source. 0= Observation, RR=Record Review, I=- Interv1ew Form C::\IS-803 (7-95) 5.44
FIRST IMPRESSIONS CHECKLIST Item to be Inspected Met Not met Facility signage visible, well lit, clean, sturdy and in good repair. Parking lot is clean, striped and well lit. Handicap stall is present and clearly marked with signage. Lawn /grounds are well kept, neat in appearance and wellmanicured without trash or clutter. Shrubbery is trimmed and flowerbeds weeded. Lawn furniture is clean, in good repair and adequate. Lawn hoses are stored and do not pose a tripping hazard. Entrance landscaped seasonally. Out of season decorations removed timely. Outside potted plants alive & well groomed. Entrances clean, well lit and without clutter. Front door clean, in good repair with weather stripping secure. Sidewalk poses no tripping hazards and is in good repair. Receptacle for cigarettes available at entrance and is emptied regularly. Lobby neatly organized, lighting appropriate (all bulbs working), low noise levels (including overhead paging). Greeted upon entrance by a staff member. Inside “potted” plants alive / well groomed. Staff members appropriately dressed with name badge. Visible office spaces neatly organized and clutter free. All areas odor free. Public restrooms clean and comfortable. Public posting information is well organized and easily accessible (i.e., State Survey Results, other required info by law). Facility has a feel of comfort and is not institutional. Hallways are free of obstruction. Dining areas are clean, neat and offer a home like appeal. Resident smoking area clean of cigarette butts and other trash. Available ashtrays and trash cans cleaned/dumped at least daily if not more often. Patio furniture clean, good repair and adequate. Patio poses no tripping hazards and is in good repair. Staff smoking area clean of cigarette butts and other trash. Available ashtrays and trash cans cleaned/dumped at least daily if not more often. Area around dumpsters are clean and clutter free. Lids on dumpsters are closed. Laundry and Dietary outside areas clean and uncluttered. Surrounding area outside storage buildings clean and uncluttered. Gutters and down spouts securely attached and function properly. Siding/brick is in good repair, not chipped, cracked or broken nor is paint chipped. Window panes are in good condition without chipped paint and no broken windows. Window screens are clean, not torn and in good repair. Corrective Action Date corrected 5.45
Page 1 and 2: Facility Self-Assessment (Mock Surv
Page 3 and 4: LONG-TERM CARE SURVEY MANUAL PREPAR
Page 5 and 6: Self-Assessment/Mock Survey Today,
Page 7 and 8: 483.60 PHARMACY F-425 Pharmacy Serv
Page 9 and 10: F-155 Refusal of Treatment. The res
Page 11 and 12: deny or withdraw consent at any tim
Page 13 and 14: F-223 Abuse. The resident has the r
Page 15 and 16: F-252 Environment. The facility mus
Page 17 and 18: F-285 Pre-Admission Screening for M
Page 19 and 20: F-320 Adjustment Difficulty. The fa
Page 21 and 22: F-353 Nursing Services/Sufficient S
Page 23 and 24: F-364 Food. Each resident receives
Page 25 and 26: F-390 Doctor Delegation of Tasks Pe
Page 27 and 28: F-454 Physical Environment. The fac
Page 29 and 30: F-494 Required Training NA. The fac
Page 31 and 32: F-512 Transportation To/From. The f
Page 33 and 34: QUALITY INDICATOR REPORT RESULTS QI
Page 35 and 36: Process - Survey Tasks Survey Task
Page 37 and 38: MEAL MONITOR ASSIGNMENT AND TIMES D
Page 39 and 40: SURVEY SCOPE & SEVERITY GRID Append
Page 41 and 42: DEPARTMENT OF HEALTH AND HUMAN SERV
Page 43 and 44: RESIDENT REVIEW WORKSHEET (continue
Page 45: DEPARTMENT OF HEALTH AND HUMAN SERV
Page 49 and 50: ADMINISTRATION CHECKLIST Area Yes N
Page 51 and 52: Instructions: 1. Complete review on
Page 53 and 54: Facility: PHYSICAL PLANT ROUNDS - I
Page 55 and 56: PHYSICAL PLANT ROUNDS - INITIAL TOU
Page 57 and 58: PHYSICAL PLANT ROUNDS - INITIAL TOU
Page 59 and 60: FIRE DRILL GRID JAN FEB MAR APR MAY
Page 61 and 62: SURVEYOR NOTES WORKSHEET Part 2 - c
Page 65 and 66: RESIDENT REVIEW WORKSHEET (continue
Page 67 and 68: QUALITY OF CARE Use probes regardin
Page 69 and 70: INVESTIGATIVE PROTOCOL HYDRATION Ob
Page 71 and 72: developed a care plan that includes
Page 73 and 74: esidents with vision or swallowing
Page 75 and 76: NON-STERILE DRESSING CHANGE Facilit
Page 77 and 78: CHART AUDIT TOOL FOCUS REVIEW RELAT
Page 79 and 80: MED PASS TECHNIQUE Resident Name/Ro
Page 83 and 84: DIETARY 5.81
Page 85 and 86: MONTHLY MEAL QUALITY REVIEW DATE: F
Page 87 and 88: Date: Person assigned: Specific are
Page 89 and 90: KITCHEN/FOOD SERVICE OBSERVATION Ta
Page 91 and 92: SOCIAL SERVICES AUDIT Date: Unit #:
Page 95 and 96: RESIDENT INTERVIEW 6. STAFF: (F223,
Page 97 and 98:
DEPARTMENT OF HEALTH AND HUMAN SERV
Page 99 and 100:
FAMILY INTERVIEW 5. (For all the it
Page 101 and 102:
GROUP INTERVIEW 3. ACTIVITIES: (F24
Page 103 and 104:
GROUP INTERVIEW 11. COUNCIL: (F243)
Page 105 and 106:
Abuse Neglect Call lights Care need
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