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: ____________________________________________________
