QUALITY OF CARE ROUNDS - Nursing Home Help

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RR SS PE IC EP F-Tag Observations Standards/CommentsF261F261F261F260F260F333F333Personal care items available, clean, stored properly, i.e.,comb/brush clean, toothbrush stored separately and covered.Night stand, dresser, closet are clean and orderlyResident equipment is clean and in good repair, i.e., suctionmachine, feeding pumps, oxygen equipment, IV stands,WC, geri-chairs, etc.Bedpans, urinals, graduates for measuring output are clean,and stored appropriatelyPiston/bulb syringes are clean, washed after each use,sanitized (per facility policy – at least every 24 hours), andare stored covered in a clean and sanitary manner. May bestored in a barrelFood items in resident’s room are stored properly, in sealedcontainersFresh water, covered container and drinking utensilavailable at all times to residentMedications stored at bedsides have Physician’s Order andare labeled appropriately98.99.100.101.102.103.104.RESIDENTF317F351F319F319F221F322Resident is well groomed and appropriately dressesfor locationIdentification band is on resident’s person; contains at leastresident’s name and admission numberResident (in or out of bed) is positioned in goodbody alignment to prevent skinbreakdown/contracturesFor “Resident at Risk” preventative measures are used(i.e., mattress overlay, wheelchair cushion, heel cuffs, footsupports)Restraints are applied correctly and released every two (2)hoursFoley catheter/tubing positioned correctly for straightdrainage, bag is below level of bladder, tubing and bag nottouching the floor, catheter is secure to body105.106.107.108.109.110.TOTAL FOR EACH CATEGORY4.9
Facility:CLINICAL VISIT ASSESSMENTSDate:Circle type of evaluation: 30 day 60 day 90 day OtherName of Evaluator:PHYSICAL PLANT & ENVIRONMENT Ratings “U” = Unsatisfactory “S” = SatisfactoryENTRANCE/LOBBY “U” “S” COMMENTSParking lot in good repair/free of literLandscape maintained/free of literExterior/trim of building maintainedSign is maintained in good repairNo “odor” is noted upon entering buildingLobby is neat/maintained-free of clutterOffice area neat/maintained-free of clutterCORRIDORS/COMMON AREAS “U” “S” COMMENTSFloors are maintained/clean/no tiles missingCorners clean/no build upWalls/ceiling are clean/stain freeLight fixtures covered/working/cleanFurniture in good repair & adequateCorridors are free of obstructionFree of pests4.10
Page 1 and 2: Quality ofCare RoundsUnlike the Moc
Page 4 and 5: RR SS PE IC EP F-Tag Observations S
Page 12 and 13: Exit lightsRESIDENT ROOMS “U”
Page 14 and 15: OTHER AREAS “U” “S” COMMENT
Page 16 and 17: Thawing foods put in refrigerator c
Page 18 and 19: SS follows upon discharge needs of
Page 20 and 21: - re-feeding/walk and dine- bowel/b
Page 22 and 23: Pumps/poles and equipment cleanWEIG
Page 24 and 25: No expired medications on handSharp
Page 26 and 27: Medical Director review of all repo
Page 28 and 29: MDS/CARE PLAN TRACKING FORMName: Ro
Page 30 and 31: HOT HOLDINGHot holding unit / steam
Page 32 and 33: Step ladders are sturdy and in good
Page 34 and 35: Yes No Buckets, tubs and pans are i
Page 36 and 37: Yes No Cleaning schedules posted an
Page 38 and 39: INFECTION CONTROL AND SAFETY SURVEI
Page 40 and 41: Yes No Electric cords for lights, r
Page 52 and 53: Yes No All wandering bracelets are
Page 54 and 55: Extended menusavailableDumpster lid
Page 56 and 57: Housekeeping Carts, Equipment, and
Page 58 and 59: Facility InspectionFacility _______
Page 60 and 61:
Facility Inspection ReportPossibleA
Page 62 and 63:
Facility Inspection ReportAREAScore
Page 64 and 65:
Figure A.7Survey tag assignment (co
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72:
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QUALITY OF CARE ROUNDS - Nursing Home Help

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