AHS Environmental Observations

• Conducted on

  Date

Triggered From the Initial Pool Process:

• Accommodation of Needs (Physical) - RI, RRI, RO

• Call Light Functioning – RI, RRI, RO

  Yes

  No

  N/A

• Sounds Levels – RI, RRI, RO

• Temperature Levels – RI, RRI, RO

• Lighting Levels – RI, RRI, RO

  Yes

  No

  N/A

• Clean Building – RI, RRI, RO

  Yes

  No

  N/A

• Building and Equipment Good Condition – RO

  Yes

  No

  N/A

• Homelike – RO

  Yes

  No

  N/A

• Lack of Hot Water – RI, RRI, RO

  Yes

  No

  N/A

• Linens – RI, RRI, RO

• Pest Control – Review if concerns are identified onsite

  Yes

  No

  N/A

• Ventilation – Review if concerns are identified onsite

  Yes

  No

  N/A

• Handrails – Review if concerns are identified onsite

  Yes

  No

  N/A

• Other Environmental Conditions – Review if concerns are identified onsite

  Yes

  No

  N/A

7 and 8

• Interview staff regarding the identified concern to determine how the facility has addressed the concern:

  Yes

  No

  N/A

• • Room set up so the resident can get around easily, get to and from the bathroom, use of the sink, or accessing drawers and closets

  Yes

  No

  N/A

• • Roommate’s personal items taking over the resident’s space

  Yes

  No

  N/A

• • Call light in reach in the resident’s room, toilet, and bathing facilities, and the appropriate type used

  Yes

  No

  N/A

• • Enough light in the resident’s room to do what the resident wants

  Yes

  No

  N/A

• • Adaptive equipment available and used

  Yes

  No

  N/A

• 1. Do residents receive services with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents?

  Yes

  No

  N/A

• No F558

FORM CMS–20061 (11/2017)

Page 1

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

Environmental Observations

• 2. Are call systems in all areas functioning properly?

  Yes

  No

  N/A

• Sound Levels: Review this CE if there are concerns by the resident, representative, or through observation of uncomfortable sound levels

  Yes

  No

  N/A

• No F919

• 3. Are comfortable sound levels maintained in all areas?

  Yes

  No

  N/A

• No F584

• 4. Are comfortable and safe temperatures maintained in all areas?

  Yes

  No

  N/A

• Lighting Levels: Review this CE if there are concerns by the resident, representative, or through observations with adequate lighting levels

  Yes

  No

  N/A

• No F584

• 5. Are proper lighting levels maintained in all areas?

  Yes

  No

  N/A

• Clean Building: Review this CE if there are concerns with the cleanliness of the building by the resident, representative, or through observations

  Yes

  No

  N/A

• No F584

FORM CMS–20061 (11/2017)

Page 2

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

Environmental Observations

• 6. Are all areas clean?

  Yes

  No

  N/A

• No F584

• Building and Equipment Good Condition: Review this CE if there are concerns with the building being in disrepair through observations

  Yes

  No

  N/A

• 7. Are all areas or equipment in good repair?

  Yes

  No

  N/A

• No F584

• 8. Is resident care equipment in safe operating condition?

  Yes

  No

  N/A

• Homelike: Review this CE if there are concerns with the resident’s room being homelike through observations

  Yes

  No

  N/A

• No F908

• Interview staff if observations revealed the resident’s room is not homelike to determine how the facility has addressed the concern

  Yes

  No

  N/A

• 9. Are the residents allowed to have personal belongings, to the extent possible, creating a homelike environment?

  Yes

  No

  N/A

• No F584

• Lack of Hot Water: Review this CE if there are concerns by the resident, representative, or through observations with the hot water being too cool

  Yes

  No

  N/A

• 10. Are water temperatures comfortable?

  Yes

  No

  N/A

• No F584

• Linens: Review this CE if there are concerns by the resident, representative, or through observations with the linens being soiled

  Yes

  No

  N/A

• Refer to the Incontinence or Infection Control pathways, as needed, for additional investigative guidance

  Yes

  No

  N/A

• 11. Are there clean bed and bath linens in good condition available for the resident?

  Yes

  No

  N/A

• No F584

FORM CMS–20061 (11/2017)

Page 3

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

Environmental Observations

• Pest Control: Review this CE if concerns are identified onsite

  Yes

  No

  N/A

• Interview staff if there are signs of pests or rodents throughout the facility to determine how the facility has addressed the concern

  Yes

  No

  N/A

• Review the facility’s pest control program

  Yes

  No

  N/A

• Review documentation of pest control intervention (e.g., commercial contractor)

  Yes

  No

  N/A

• 12. Does the facility maintain an effective pest control program so that the facility is free of pests and rodents?

  Yes

  No

  N/A

• Interview staff if there are odors throughout the facility to determine how the facility has addressed the concern

  Yes

  No

  N/A

• No F925

• Ventilation: Review this CE if concerns are identified onsite

  Yes

  No

  N/A

• 13. Is there adequate ventilation in all areas?

  Yes

  No

  N/A

• No F923

• Handrails: Review this CE if concerns are identified onsite

  Yes

  No

  N/A

• 14. Are handrails accessible and securely affixed to the walls?

  Yes

  No

  N/A

• No F924

• Other Environmental Conditions: Review this CE if concerns are identified onsite

  Yes

  No

  N/A

• 15. Does the facility provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public?

  Yes

  No

  N/A

• No F921

FORM CMS–20061 (11/2017)

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