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Finding a long term care facility for a loved one can be a difficult decision.  It is a decision that is likely to impact the rest of your loved one’s life.  This is an easy-to-use facility evaluation form.  Complete one for each facility you visit.

Facility Evaluation

Overall rating of facility after tour and research: 1  2  3  4  5  6  7  8  9  10

Date or Tour: _________________  Time of Day: _____________________

Facility Name:____________________________________________________

Type of facility: ____________________Distance from your home: ___________

Cost per:     Day: _______________       Month: ______________

Is there a waitlist: ___ Y  ___ N  What is the length of the wait list: ____________

___  Check facility inspections on Florida Health Finder or other state website that tracks facilities

___  Check facility quality score (if nursing home) on Medicare’s Nursing Home Compare site

___  Ask for and review the facility’s most recent inspection report

___  Ask for and review calendar of facility events (are these activities you loved one can or would participate in)

___  Ask for and review copies of admission contracts and paperwork that would need to be signed

___  Are there posters in the facility showing the Long Term Care Ombudsman’s telephone number

___  Are there posters in the facility showing the list of Residents’ Rights

Number of residents in the facility:  ________________

Number of rooms in facility: ___________

Room size:  Private room ___________________

Semi-private room ______________________

Number of residents in a semi-private room: ______________

Is there a resident or family council?  ___ Y   ___ N  It meets: ________________

Meal eaten:  __ Breakfast   __ Lunch   __ Dinner   __ Snack
Food appearance and taste: _____________________________________________________________

Appearance of dining facilities: _____________________________________________________________

General appearance of facility:  _____________________________________________________________

General cleanliness of facility: _____________________________________________________________

Smell of facility: _____________________________________________________________

General appearance of facility rooms: ________________________________________________________

Where are the residents in the facility? ________________________________________________________

Are the residents engaged in activities? ________________________________________________________

What is the staff to resident ratio:  Day shift ______   Night shift ______  # of nurses per shift ________

The facility has on _____ staff nurses or _____ nursing agency to staff facility.

What is the facility staff turn-over rate? ____________________________________________________

Do residents control their own routines such as getting up and going to bed when they choose?  _______________________________

What part of the residents’ routine is preset? ____________________________________________

What did you dislike about this facility: ____________________________________________________