Senior Living

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Total current census?

EVALUATION

• Overall risk rating?

  Above Average

  Average

  Below Average

• Property Coverage Rating?

  Above Average

  Average

  Below Average

• General Liability Coverage Rating?

  Above Average

  Average

  Below Average

• Fleet Coverage Rating?

  Above Average

  Average

  Below Average

OVERVIEW

• Ownership?

  For Profit

  Non-Profit

• Name of owner:

• Board of Directors?

  Yes

  No

  N/A

• Number of buildings?

  1

  2

  3

  4

  More than 4 stories

• Age of building(s)?

• Date operations began?

HEALTHCARE ENVIRONMENT

• Independent Living?

  Yes

  No

  N/A

• Number of IL apartments?

• Houses, Villas or Duplexes?

  Select Houses Villas Duplexes

  • Houses
  • Villas
  • Duplexes

• Number of houses, villas or duplexes?

• Skilled Nursing?

  Yes

  No

  N/A

• Total number of licensed beds?

• Total current census?

• Number of current private pay residents?

• Number of current Medicare residents?

• Number of current Medicaid residents?

• Are all beds dully certified?

  Yes

  No

  N/A

• Number of licensed Medicare beds?

• Number of licensed Medicaid beds?

• What type of emergency notification system is used for skilled nursing residents?

  Select Pendant Pull cord Pull Cord in Bathroom Push button at bed pull cord in bedroom

  • Pendant
  • Pull cord
  • Pull Cord in Bathroom
  • Push button at bed
  • pull cord in bedroom

• How many snacks are provided each day?

  1

  2

  3

  4

  As requested

• Any skilled nursing residents under age 60?

  Yes

  No

  N/A

• Number of residents under age 60?

• Inquire about their diagnosis to ensure those under 60 are proper for this environment.

• Memory Care or CCDI unit in skilled care?

  Yes

  No

  N/A

• Number of residents in this area?

• How many meals are served each day?

  1

  2

  3

• Assisted Living?

  Yes

  No

  N/A

• Number of residents licensed for?

• Current census?

• Any residents under age 60 in Assisted Living?

  Yes

  No

  N/A

• What type of call system is used in Assisted Living?

  Select Pendant Pull cord Pull Cord in Bathroom Push button at bed pull cord in bedroom

  • Pendant
  • Pull cord
  • Pull Cord in Bathroom
  • Push button at bed
  • pull cord in bedroom

• How many meals provided each day?

  1

  2

  3

• Memory Care Residents in Assisted living?

  Yes

  No

  N/A

• Number of a Memory Care licensed for?

• Current Memory Care census?

MEDICATION MANAGEMENT

• Skilled Nursing Medication Management

  Yes

  No

  N/A

• Type of medication dispensing system used in Skilled Nursing?

  Select Bubble pack Strip pack Pharmacy bottle Some residents self medicate

  • Bubble pack
  • Strip pack
  • Pharmacy bottle
  • Some residents self medicate

• Is a medication cart used?

  Yes

  No

  N/A

• Is the cart locked in a secure area when not in use?

  Yes

  No

  N/A

• Are there residents in skilled nursing who self administer medications?

  Yes

  No

  N/A

• Is there a formal assessment done for self administration of medication?

  Yes

  No

  N/A

• Type of medication storage used by those who self administer medication?

  Select Lock box in room Med Cart Other

  • Lock box in room
  • Med Cart
  • Other

• Are medication technicians used in the long term care environment?

  Yes

  No

  N/A

• Who provides training?

• Is training documented?

  Yes

  No

  N/A

• Assisted Living Medication Management

  Yes

  No

  N/A

• Are medication changes for Assisted Living residents reviewed by a nurse?

  Yes

  No

  N/A

• Are there residents in assisted living who self administer their own medications?

  Yes

  No

  N/A

• Is an assessment done for self administration of medications?

  Yes

  No

  N/A

• What type of medication storage is used by residents who self administer medications in Assisted Living?

  Select Lock box in room Med Cart Other

  • Lock box in room
  • Med Cart
  • Other

• Staff in Assisted Living administer who administer (Nurses) or assist (care staff) with medications?

  Select Nurses Med techs All staff

  • Nurses
  • Med techs
  • All staff

• Is their a formal training program in place for unlicensed staff to prepare them for assisting residents with medication?

  Yes

  No

  N/A

• Is the training documented?

  Yes

  No

  N/A

• Who provides the training?

• What type of medication dispensing system is used by staff in Assisted Living?

  Select Bubble pack Strip pack Pharmacy bottle Some residents self medicate

  • Bubble pack
  • Strip pack
  • Pharmacy bottle
  • Some residents self medicate

• Is a medication cart used?

  Yes

  No

  N/A

• Is the cart locked in a secure room when not in use?

  Yes

  No

  N/A

• Are Independent Living residents provided any medication management?

  Yes

  No

  N/A

• Is this service provided by a nurse, med tech or all staff?

  Select Nurses Med techs All staff

  • Nurses
  • Med techs
  • All staff

• Where are medication for IL residents stored when staff assists?

  Select Lock box in room Med Cart Other

  • Lock box in room
  • Med Cart
  • Other

OUTSIDE SERVICES

• Does community provide outside services for Meals on Wheels?

  Yes

  No

  N/A

• Who delivers the meals and to whom are they delivered?

• Is Home Health provided outside the community?

  Yes

  No

  N/A

• Is Hospice care provided to those outside the community?

  Yes

  No

  N/A

• Is Respite Care provided in the community?

  Yes

  No

  N/A

• Is Adult Daycare provided in the community?

  Yes

  No

  N/A

STAFFING

• Is this a Continuing Care Retirement Community?

  Yes

  No

  N/A

• Name of Executive Director?

• How many years experience as an Executive Director?

• How many years with community?

• Is there a Skilled Nursing Administrator?

  Yes

  No

  N/A

• Name of Skilled Nursing Administrator?

• How many years as a licensed Administrator?

• How many years at this community.

• Is there an Assisted Living Administrator?

  Yes

  No

  N/A

• Name of Assisted Living Administrator?

• How many years as a licensed Assisted Living Administrator?

• How many years with company?

• Is there a Director of Nurses or Nurse Manager?

  Yes

  No

  N/A

• Is a Registered Nurse required for this position?

  Yes

  No

  N/A

• Name of DON or Nurse Manager?

• How many years as a nurse?

• How long in current position?

• How long at community?

• If location is a CCRC with Skilled Nursing, Assisted Living and Memory Care is there more than one Nurse Manager?

  Yes

  No

  N/A

• Is there an Assistant Director of Nursing?

  Yes

  No

  N/A

• Name of ADON?

• RN or LPN required for this position?

  Select LPN RN

  • LPN
  • RN

• How many years experience as a nurse?

• How many years experience at this position?

• How many years as an employee of this community?

• Do you have an MDS Coordinator on staff?

  Yes

  No

  N/A

• How many MDS coordinators are on staff?

  Select 1 2 3 4 5

  • 1
  • 2
  • 3
  • 4
  • 5

LINE STAFF

• Total number of staff?

• Number of Maintenance Staff?

• Number of Housekeeping Staff?

• Number of Dietary Staff?

• Number of care staff to include Nurses and Care Staff?

• Current PPD?

1st Shift Staffing?

• Skilled Nursing Staffing

  Yes

  No

  N/A

• # RN

• # LPN

• # CNA

• Assisted Living Staffing

  Yes

  No

  N/A

• # RN

• # LPN

• # Caregiver/CNA

• Assisted Living Memory Care Staffing

  Yes

  No

  N/A

• # RN

• # LPN

• # Caregivers/CNA

2nd Shift Staffing

• Skilled Nursing Staffing

  Yes

  No

  N/A

• # RN

• # LPN

• # CNA

• Assisted Living Staffing

  Yes

  No

  N/A

• # RN

• # LPN

• # Caregiver/CNA

• Assisted Living Memory Care Staffing

  Yes

  No

  N/A

• # RN

• # LPN

• # Caregivers/CNA

3rd Shift Staffing

• Skilled Nursing Staffing

  Yes

  No

  N/A

• # RN

• # LPN

• # CNA

• Assisted Living Staffing

  Yes

  No

  N/A

• # RN

• # LPN

• # Caregiver/ CNA

• Assisted Living Memory Care Staff

  Yes

  No

  N/A

• # RN

• # LPn

• # Caregiver/CNA

• Agency staff used?

  Yes

  No

  N/A

• Are background checks done for employees?

  Yes

  No

  N/A

• Who conducts the background checks?

• Are back ground checks done for volunteers?

  Yes

  No

  N/A

• Are drug test done for employees?

  Select Pre-employment Random Reasonable suspicion Post injury No

  • Pre-employment
  • Random
  • Reasonable suspicion
  • Post injury
  • No

TRAINING

• Staff training narrative: Staff training is at or above the industry standard.

• On-line training used?

  Yes

  No

  N/A

• Name of on-line training program?

• How often are in-house in-services done?

  Select Upon hire Monthly Quarterly Bi-annually Annually As needed

  • Upon hire
  • Monthly
  • Quarterly
  • Bi-annually
  • Annually
  • As needed

STATE SURVEY RESULTS

• Skilled Nursing Survey

  Yes

  No

  N/A

• Last survey date:

• Results of survey:

• Have all corrective actions been implemented?

  Yes

  No

  N/A

• Assisted Living Survey

  Yes

  No

  N/A

• Last survey date?

• Results of survey:

• If Memory Care is present, how many of the tags were for the Memory Care area?

• Have all corrective actions been implemented?

  Yes

  No

  N/A

CLINICAL RISK MANAGEMENT PROGRAM

• Clinical risk management narrative: All components of the formal documented policies and procedures are reviewed annually and adjustments made by management are done on an as needed basis. Current clinical risk program is considered average and is the industry standard.

Safety Committee

• Formal Safety Committee in place?

  Yes

  No

  N/A

• In Skilled Nursing?

  Yes

  No

  N/A

• In Assisted Living?

  Yes

  No

  N/A

• How often do they meet?

  Select Monthly Quarterly Bi-annually Annually As needed

  • Monthly
  • Quarterly
  • Bi-annually
  • Annually
  • As needed

• Are meetings documented?

  Yes

  No

  N/A

• Are resident accidents discussed at the Safety Committee meetings?

  Yes

  No

  N/A

• Who are members of the Safety Committee?

  Select Administrator DON Unit Managers Line Staff Department Heads

  • Administrator
  • DON
  • Unit Managers
  • Line Staff
  • Department Heads

FIRE DRILLS/DISASTER DRILLS

• Are fire drills conducted?

  Yes

  No

  N/A

• How often are they conducted?

  Monthly rotating shifts

  Quarterly rotating shifts

• Are procedural issues discussed with staff and corrected immediately?

  Yes

  No

  N/A

• Are results of Fire Drills reviewed by Safety Committee or Quality Assurance Committee?

  Yes

  No

  N/A

• Are they conducted in Skilled Nursing?

  Yes

  No

  N/A

• Are they conducted in Assisted Living?

  Yes

  No

  N/A

• Are they conducted in Memory Care?

  Yes

  No

  N/A

• Are they conducted in Independent Living?

  Yes

  No

  N/A

• Are disaster drills conducted in all areas? ( Tornado?, Gas Leak?, Bomb Threat?)

  Yes

  No

  N/A

• Is there a disaster plan in place for all areas?

  Yes

  No

  N/A

• Does it include an agreement with another community to house residents in case of disaster?

  Yes

  No

  N/A

QUALITY ASSURANCE COMMITTEE

• Is there a Quality Assurance Committee in Skilled Nursing?

  Yes

  No

  N/A

• How often does the committee meet?

  Weekly

  Monthly

  Quarterly

  Annually

  As needed

• Who are members of the Quality Asurance Committee?

  Select DON Nurse managers Administrator Physician Department Heads

  • DON
  • Nurse managers
  • Administrator
  • Physician
  • Department Heads

• Does your Medical Director attend?

  Yes

  No

  N/A

• Does a pharmacy representative attend?<br>

  Yes

  No

  N/A

• Do therapy representatives attend?

  Yes

  No

  N/A

• Any other outside parties attend?

• Do you have any kind of Quality Care Committee in Assisted Living?

  Yes

  No

  N/A

FALL MANAGEMENT

• Are residents assessed for falls on or before admission?

  Yes

  No

  N/A

• Skilled Nursing?

  Yes

  No

  N/A

• How do staff know a resident is at risk for falls?

  Select Chart E-chart Care Plan Colored dot on chart Posted in room

  • Chart
  • E-chart
  • Care Plan
  • Colored dot on chart
  • Posted in room

• Pressure alarms used?

  Yes

  No

  N/A

• Lipped mattresses used?

  Yes

  No

  N/A

• Gerry chairs used?

  Yes

  No

  N/A

• Any other preventions used?

  Yes

  No

  N/A

• Assisted Living?

  Yes

  No

  N/A

• How do staff know a resident in Assisted Living is at risk for falls?

  Select Chart E-chart Care Plan Colored dot on chart Posted in room

  • Chart
  • E-chart
  • Care Plan
  • Colored dot on chart
  • Posted in room

• Preventions used?

  Yes

  No

  N/A

• Memory Care?

  Yes

  No

  N/A

• How do staff know a resident in Memory Care is at risk for falls?

  Select Chart E-chart Care Plan Colored dot on chart Posted in room

  • Chart
  • E-chart
  • Care Plan
  • Colored dot on chart
  • Posted in room

• Preventions used?

  Yes

  No

  N/A

RESTRAINTS

• Type of side rails used?

  Select Half Full Repositioning

  • Half
  • Full
  • Repositioning

• Do you have a restraint policy in place?

  Yes

  No

  N/A

• Are you a restraint free community?

  Yes

  No

  N/A

LIFTS AND TRANSFERS

• Type of lifts used?

  Select Full Lifts Sit to stand lifts Other

  • Full Lifts
  • Sit to stand lifts
  • Other

• Who trains new staff on proper usage of lifts?

• Is training documented?

  Yes

  No

  N/A

• Is there a maintenance plan in place to maintain the lifts in proper working order?

  Yes

  No

  N/A

• Who provides maintenance on lifts?

  Select Maintenance Outside Vendor

  • Maintenance
  • Outside Vendor

• Are gait belts used for transfers?

  Yes

  No

  N/A

• Who provides training for proper use of gate belts?

• Is training documented?

  Yes

  No

  N/A

ADMISSION/ DISCHARGE

• Is there a formal admission packet in place for all areas of the community?

  Yes

  No

  N/A

• Does the admission packet address when a resident is no longer appropriate for their current level of care and should be moved to a higher level of care?

  Yes

  No

  N/A

• Does the admission packet address resident conduct policies for all levels of care?

  Yes

  No

  N/A

RESIDENT COMMUNICATION AND MONITORING

• Are residents assessed before admission?

  Yes

  No

  N/A

• In Skilled Nursing?

  Yes

  No

  N/A

• Residents are assessed before admission in Skilled Nursing by:

  Select Nurse Admissions Physician Administrator Other

  • Nurse
  • Admissions
  • Physician
  • Administrator
  • Other

• Are residents assessed by a physician per Medicare Guidelines?

  Yes

  No

  N/A

• In Assisted Living?

  Yes

  No

  N/A

• Residents are assessed before admission by:

  Select Nurse Admissions Physician Administrator Other

  • Nurse
  • Admissions
  • Physician
  • Administrator
  • Other

• After admission, how often is an Assisted Living resident assessed by a physician?

  Select Monthly Quarterly Bi-annually Annually As needed

  • Monthly
  • Quarterly
  • Bi-annually
  • Annually
  • As needed

• After admission, how often is residents condition assessed and documented in Assisted Living by staff?

  Daily

  Weekly

  Monthly

  As needed

  Seldom

• What would trigger family notification? Fall, altercation, change in medications, room change, any change in contrition.

E-CHARTING

• Is e-charting used?

  Yes

  No

  N/A

• Does it include e-mars?

  Yes

  No

  N/A

• Name of e-charting in use?

SKIN TEARS/ DECUBITUS CONTROL

• Do you currently have any residents with pressure ulcers in skilled nursing?

  Yes

  No

  N/A

• How many?

• How often do staff assess resident's skin in Skilled nursing?

  Select Daily Weekly with each shower

  • Daily
  • Weekly
  • with each shower

• Is there a wound care nurse on staff?

  Yes

  No

  N/A

• Are special mattresses used?

  Yes

  No

  N/A

• ROHO/gel cushions used in chairs?

  Yes

  No

  N/A

• Is a wound care clinic used by residents when necessary?

  Yes

  No

  N/A

• Is Dietary involved in prevention?

  Yes

  No

  N/A

• Wounds in Assisted Living?

  Yes

  No

  N/A

• How many?

• How often does staff assess residents' skin for wounds?

  Select Daily Weekly Monthly With each bath Never

  • Daily
  • Weekly
  • Monthly
  • With each bath
  • Never

• Is Home Health involved in wound care in Assisted Living?

  Yes

  No

  N/A

• Wounds in Memory care?

  Yes

  No

  N/A

• How many?

• How often does staff assess resident's skin?

  Select Daily Weekly Monthly With each bath Never

  • Daily
  • Weekly
  • Monthly
  • With each bath
  • Never

• Is Home Health involved in wound care for Memory Care residents?

  Yes

  No

  N/A

RESIDENT ABUSE TRAINING

• Is resident abuse training done upon hire?

  Yes

  No

  N/A

• When is resident abuse training updated after hire?

  Select Monthly Quarterly Bi-annually Annually As needed

  • Monthly
  • Quarterly
  • Bi-annually
  • Annually
  • As needed

• Is the training documented?

  Yes

  No

  N/A

• Where is training documented?

  Select Employee's file In-service book Not documented

  • Employee's file
  • In-service book
  • Not documented

• Are volunteers required to complete resident abuse training?

  Yes

  No

  N/A

• Is there a formal policy and procedure in place for investigating and reporting abuse?

  Yes

  No

  N/A

• Who is in charge of investigating abuse?

  Select Administrator DON Unit Managers Line Staff Department Heads

  • Administrator
  • DON
  • Unit Managers
  • Line Staff
  • Department Heads

DO NOT RESUSCITATE

• Are there residents with Do Not Resucitate orders in Skilled Nursing?

  Yes

  No

  N/A

• Is the DNR a state provided form or a physician's order?

  Select State Form Physician's Order

  • State Form
  • Physician's Order

• Where is the form kept?

  Select Chart E-chart Care Plan Colored dot on chart Posted in room

  • Chart
  • E-chart
  • Care Plan
  • Colored dot on chart
  • Posted in room

• Does a physician have to sign the form or order?

  Yes

  No

  N/A

• Is the form or acknowledgement signed by the resident, family member or representative of the resident?

  Yes

  No

  N/A

• How are resident in Skilled Nursing with DNRs identified to staff?

  Select Chart E-chart Care Plan Colored dot on chart Posted in room

  • Chart
  • E-chart
  • Care Plan
  • Colored dot on chart
  • Posted in room

• If a resident is found unresponsive and they are a FULL CODE is CPR started?

  Yes

  No

  N/A

• Which staff in Skilled Nursing are trained in CPR?

  Select Nurses Med techs All staff

  • Nurses
  • Med techs
  • All staff

• Is training documented?

  Yes

  No

  N/A

• Are there residents in Assisted Living and/or Memory Care with Do Not Resucitate Orders?

  Yes

  No

  N/A

• In Assisted Living or Memory Care is the form a state provided form or physicians order?

  Select State Form Physician's Order

  • State Form
  • Physician's Order

• Where is the form kept?

  Select Chart E-chart Care Plan Colored dot on chart Posted in room

  • Chart
  • E-chart
  • Care Plan
  • Colored dot on chart
  • Posted in room

• Is the form signed by a physician?

  Yes

  No

  N/A

• Is the form signed by the resident, a family member or representative of the resident?

  Yes

  No

  N/A

• How are Assisted Living/Memory Care residents with DNRs identified by staff?

  Select Chart E-chart Care Plan Colored dot on chart Posted in room

  • Chart
  • E-chart
  • Care Plan
  • Colored dot on chart
  • Posted in room

• If a resident is found unresponsive and is a FULL CODE, is CPR implemented?

  Yes

  No

  N/A

• Which staff members in Assisted Living/Memory Care are trained in CPR?

  Select All staff All care staff Nurses

  • All staff
  • All care staff
  • Nurses

• Is CPR training documented?

  Yes

  No

  N/A

• Is CPR performed on Independent Living Residents?

  Yes

  No

  N/A

• What staff members perform CPR on IL residents?

  Select Nurses Med techs All staff

  • Nurses
  • Med techs
  • All staff

• If a resident is found unresponsive and the event was not witnessed is CPR started if the resident is a full code?

  Yes

  No

  N/A

• How do staff members know if an IL resident has DNR wishes?

ELOPEMENT RISK MANAGEMENT

• Are skilled nursing residents assessed on or before admission for elopements?

  Yes

  No

  N/A

• How often are re-assessments done?

  Select Daily Weekly Monthly Quarterly Change in condition As needed

  • Daily
  • Weekly
  • Monthly
  • Quarterly
  • Change in condition
  • As needed

• Are Skilled Nursing residents required to sign out before leaving the community?

  Yes

  No

  N/A

• Are doors locked at all times?

  Yes

  No

  N/A

• Are all doors alarmed?

  Yes

  No

  N/A

• How are door alarms silenced?

  Select Code Key

  • Code
  • Key

• How often are door alarms tested?

  Select Per Shift Daily Weekly Monthly As Needed

  • Per Shift
  • Daily
  • Weekly
  • Monthly
  • As Needed

• Who tests the door alarms?

  Select Maiantenance Nurses Care Staff All Staff

  • Maiantenance
  • Nurses
  • Care Staff
  • All Staff

• Is testing documented?

  Yes

  No

  N/A

• Is there a wander guard system in place?

  Yes

  No

  N/A

• How often are transmitters tested?

  Select Per Shift Daily Weekly Monthly As Needed

  • Per Shift
  • Daily
  • Weekly
  • Monthly
  • As Needed

• What staff members test the transmitters?

  Select Maiantenance Nurses Care Staff All Staff

  • Maiantenance
  • Nurses
  • Care Staff
  • All Staff

• Is testing documented?

  Yes

  No

  N/A

• Is there video monitoring in the community?

  Yes

  No

  N/A

• Where are cameras located?

  Select All exits Hallways Nurses stations

  • All exits
  • Hallways
  • Nurses stations

• Is there an elopement policy in place?

  Yes

  No

  N/A

• How often are staff in-serviced on the elopement policy and procedures?

  Select Upon hire Monthly Quarterly Bi-annually Annually As needed

  • Upon hire
  • Monthly
  • Quarterly
  • Bi-annually
  • Annually
  • As needed

• How do staff know who the residents are who are at risk for elopement?

  Select Chart E-chart Care Plan Colored dot on chart Posted in room

  • Chart
  • E-chart
  • Care Plan
  • Colored dot on chart
  • Posted in room

• Is training documented?

  Yes

  No

  N/A

• How often is the elopement policy reviewed and updated by management?

  Select Monthly Quarterly Bi-annually Annually As needed

  • Monthly
  • Quarterly
  • Bi-annually
  • Annually
  • As needed

• Is a formal elopement risk assessment done before admission in Assisted Living/Memory Care?

  Yes

  No

  N/A

• How often are reassessments done?

  Weekly

  Monthly

  Quarterly

  Annually

  As needed

• How do Assisted Living Staff identify residents at risk for elopement?

  Select Chart E-chart Care Plan Colored dot on chart Posted in room

  • Chart
  • E-chart
  • Care Plan
  • Colored dot on chart
  • Posted in room

• Are residents required to sign out before leaving Assisted Living/Memory Care?

  Yes

  No

  N/A

PETS & THE EDEN ALTERNATiVE

• Are pets allowed in the community?

  Yes

  No

  N/A

• Do residents within the community have pets?

  Yes

  No

  N/A

• Is there a formal pet policy in place for residents?

  Yes

  No

  N/A

• Does the policy include providing up-to-date veterinary health reports before pets are brought to the community?

  Yes

  No

  N/A

• Is there a formal policy in place for visitors who bring pets into the community?

  Yes

  No

  N/A

SLIPS, TRIPS AND FALL EXPOSURE

• Type of flooring in resident corridors?

  Select VCT tile Carpet Ceramic tile Polished concrete Wood Non-slip tile Linoleum

  • VCT tile
  • Carpet
  • Ceramic tile
  • Polished concrete
  • Wood
  • Non-slip tile
  • Linoleum

• Type of flooring in employee corridors?

  Select VCT tile Carpet Ceramic tile Polished concrete Wood Non-slip tile Linoleum

  • VCT tile
  • Carpet
  • Ceramic tile
  • Polished concrete
  • Wood
  • Non-slip tile
  • Linoleum

• Type of flooring in resident dining areas?

  Select VCT tile Carpet Ceramic tile Polished concrete Wood Non-slip tile Linoleum

  • VCT tile
  • Carpet
  • Ceramic tile
  • Polished concrete
  • Wood
  • Non-slip tile
  • Linoleum

• Type of flooring in commercial kitchen?

  Select VCT tile Carpet Ceramic tile Polished concrete Wood Non-slip tile Linoleum

  • VCT tile
  • Carpet
  • Ceramic tile
  • Polished concrete
  • Wood
  • Non-slip tile
  • Linoleum

• Type of flooring in resident bathroom?

  Select VCT tile Carpet Ceramic tile Polished concrete Wood Non-slip tile Linoleum

  • VCT tile
  • Carpet
  • Ceramic tile
  • Polished concrete
  • Wood
  • Non-slip tile
  • Linoleum

• Type of flooring in common area bathrooms?

  Select VCT tile Carpet Ceramic tile Polished concrete Wood Non-slip tile Linoleum

  • VCT tile
  • Carpet
  • Ceramic tile
  • Polished concrete
  • Wood
  • Non-slip tile
  • Linoleum

• Are exterior sidewalks and parking lots in good repair?

  Yes

  No

  N/A

• List issues with parking lot and/ or sidewalk:

PUBLIC/PRIVATE PROTECTiON

• Distance to closest fire hydrant (In feet).

• Distance to fire department (In miles)

• Is fire department career or volunteer?

  Select Career Volunteer Both

  • Career
  • Volunteer
  • Both

• Are all sides of the property accessible to the fire department?

  Yes

  No

  N/A

• Describe why the fire department can't access all sides of the building:

• Are adequate fire extinguishers available?

  Yes

  No

  N/A

• Public/Private Protection Narrative: Access to the facility would be considered adequate and no concers were noted at time of survey.

• Number of smoke division?

• Construction quality?

  Good

  Fair

  Poor

• Number of stories?

  1

  2

  3

  4

  More than 4 stories

LIFE SAFETY

• Life safety narrative: Life Safety for the community is adequate and inspected by the state Life Safety and Fire Marshall on an annual basis. The buildings and safety systems are designed for occupancy and no concerns are noted at this time.

Fire, Sprinklers, Alarms

• Company who services sprinklers?

• Alarm monitoring company?

• Company that services UL 300 system?

• Company who services fire extinguishers?

• Do all buildings have heat and smoke detection sensors?

  Yes

  No

  N/A

• Are all buildings 100% sprinklered?

  Yes

  No

  N/A

• Is it a wet or dry system?

  Wet

  Dry

• Are attics sprinklered?

  Yes

  No

  N/A

• Wet or dry sprinklered?

  Wet

  Dry

• Do you have parking garages?

  Yes

  No

  N/A

• Are they sprinklered?

  Yes

  No

  N/A

• Wet or dry sprinklered?

  Wet

  Dry

• Sprinkler system meets NFPA25?

  Yes

  No

  N/A

• Is the sprinkler system over 50 years old?

  Yes

  No

  N/A

• Is the system protected during cold and freezing weather?

  Yes

  No

  N/A

• Are sprinkler heads subject to damage covered with guards?

  Yes

  No

  N/A

• Are sprinkler heads clear of obstruction by 18"?

  Yes

  No

  N/A

• Are sprinkler heads clear of damage, paint, corrosion, etc.?

  Yes

  No

  N/A

• Do all Fire Department connections have caps in place?

  Yes

  No

  N/A

• Is a building layout available?

  Yes

  No

  N/A

• How often are kitchen vent hoods cleaned by staff?

  Daily

  Weekly

  Monthly

  As needed

  Seldom

• How often are kitchen hoods cleaned by a professional?

  Select Monthly Quarterly Bi-annually Annually

  • Monthly
  • Quarterly
  • Bi-annually
  • Annually

• What commercial cleaning company cleans the kitchen hood vents?

EMERGENCY POWER

• Do you have a generator?

  Yes

  No

  N/A

• Type of fuel used in generator?

  Select Natural Gas Butane Gasoline Diesel

  • Natural Gas
  • Butane
  • Gasoline
  • Diesel

• How much fuel for generator is stored on-site?

• If emergency fuel is not stored on-site where is it obtained?

• How much load will generator provide?

• How often is generator load tested?

  Daily

  Weekly

  Monthly

  As needed

  Seldom

• How long does the load test last?

• Where are enunciator panels located?

• Do you test your emergency lighting?

  Yes

  No

  N/A

• How often are emergency lights tested?

  Weekly

  Monthly

  Quarterly

  Annually

  As needed

• Are emergency exits clear from clutter?

  Yes

  No

  N/A

• Are there lighted EXiT signs at all exits?

  Yes

  No

  N/A

• Do windows lock from the inside?

  Yes

  No

  N/A

• How far will windows open?

• Are windows easily accessible for emergency response personnel?

  Yes

  No

  N/A

SNOW REMOVAL

• Who does your snow removal?

  Select Maintenance Contractor

  • Maintenance
  • Contractor

CONSULTANTS AND CONTRACTORS

• Do you have any nurse consultants?

  Yes

  No

  N/A

• Name of nurse consultant or name of company which provides consulting?

• Do you have a pharmacy consultant?

  Yes

  No

  N/A

• Name of pharmacy consultant or company who provides consultant?

• Is therapy outsourced?

  Yes

  Employees of community

• Name of therapy provider?

• Registered Dietician as a consultant?

  Yes

  No

  N/A

• Name of Registered Dietician?

• Is there a contracted Social Worker?

  Yes

  No

  N/A

• Name of Social Worker or company providing services?

• Are Hospice services provided from outside vendors?

  Yes

  No

  N/A

• Are Home Health Care services provided by outside vendors?

  Yes

  No

  N/A

• Are beautician services provided within the community?

  Yes

  No

  N/A

• Are Certificates of Insurance on file for all contractors?

  Yes

  No

  N/A

• Are current licenses/credentials on file for the above consultants/subcontractors?

  Yes

  No

  N/A

• Do you have a contract with your Medical Director?

  Yes

  No

  N/A

• Do you have a Certificate of Insurance for the Medical Director?

  Yes

  No

  N/A

• Do you have current copies of the medical director's credentials on file?

  Yes

  No

  N/A

COMMUNiTY TRANSPORTATION AND DRIVER TRAINING

• Are any buses in the fleet?

  Yes

  No

  N/A

• Number of buses?

  1

  2

  3

  4

  As requested

• Condition of buses?

  Above Average

  Average

  Below Average

• Are there any vans in the fleet?

  Yes

  No

  N/A

• Number of vans?

  1

  2

  3

  4

  As requested

• Condition of vans?

  Good

  Fair

  Poor

• Are there any cars in the fleet?

  Yes

  No

  N/A

• Number of cars?

  Yes

  No

  N/A

• Condition of cars?

  Good

  Fair

  Poor

• Are there any trucks in the fleet?

  Yes

  No

  N/A

• Number of trucks?

  1

  2

  3

• Condition of trucks?

  Good

  Fair

  Poor

• Is there a written personal use policy for automobiles?

  Yes

  No

  N/A

• Are MVR checks done for drivers?

  Yes

  No

  N/A

• By whom?

• How often are MVR checks updated?

• How often are automobiles used?

  Daily

  Weekly

  Monthly

  As needed

  Seldom

• Average radius in miles automobiles are driven per trip?

• Who provides driver training?

• Is training documented?

  Yes

  No

  N/A

• Does the training include properly securing wheelchairs?

  Yes

  No

  N/A

• Is a CDL or Chauffeur license required for any of your automobiles?

  Neither

  Both

  Chauffeur

  CDL

• Who does automobile maintenance and repairs?

• How often is maintenance done?

  Daily

  Weekly

  Monthly

  As needed

  Seldom

• Are automobiles stored in a garage?

  Yes

  No

  Some are

PROPERTY

• What lies to the north of the property?

  Select Businesses Single family homes Apartments Church Vacant lots

  • Businesses
  • Single family homes
  • Apartments
  • Church
  • Vacant lots

• What lies to the south of the property?

  Select Businesses Single family homes Apartments Church Vacant lots

  • Businesses
  • Single family homes
  • Apartments
  • Church
  • Vacant lots

• What lies to the east of the property?

  Select Businesses Single family homes Apartments Church Vacant lots

  • Businesses
  • Single family homes
  • Apartments
  • Church
  • Vacant lots

• What lies to the west of the property?

  Select Businesses Single family homes Apartments Church Vacant lots

  • Businesses
  • Single family homes
  • Apartments
  • Church
  • Vacant lots

CONSTRUCTION TYPE

• Roofing material?

  Select TIn Shingle Tile Plastic Membrane Tar

  • TIn
  • Shingle
  • Tile
  • Plastic Membrane
  • Tar

• Roof slope?

  Select Sloping Flat Hip

  • Sloping
  • Flat
  • Hip

• Siding?

  Select Brick Vinyle Stucco Block Wooden

  • Brick
  • Vinyle
  • Stucco
  • Block
  • Wooden

• Framing?

  Select Wooden Aluminum Metal

  • Wooden
  • Aluminum
  • Metal

HEAT SOURCE

• Heat source in common areas?

  Select Boilers Electric PTAC Gas furnace

  • Boilers
  • Electric
  • PTAC
  • Gas furnace

• Heat source in resident rooms?

  Select Boilers Electric PTAC Gas furnace

  • Boilers
  • Electric
  • PTAC
  • Gas furnace

• Are there any fireplaces?

  Yes

  No

  N/A

• How many fireplaces?

  1

  2

  3

• Are they gas, electric or wood burning?

  Select Gas Electric Wood burning

  • Gas
  • Electric
  • Wood burning

MODIFICATIONS

• Any recent modifications to building(s)?

  Yes

  No

  N/A

• Please list modifications with date modifications were completed:

SMOKING

• Are residents allowed to smoke?

  Yes

  No

  N/A

• Is a smoking assessment completed?

  Yes

  No

  N/A

• In Skilled Nursing?

  Yes

  No

  N/A

• In Assisted Living?

  Yes

  No

  N/A

• Are residents accompanied by a staff member to smoke in Skilled Nursing?

  Yes

  No

  N/A

• Are IL residents allowed to smoke?

  Yes

  No

  N/A

• Do residents a smoke inside or outside?

  Select Inside Outside In a designated area

  • Inside
  • Outside
  • In a designated area

INSURANCE CLAIMS

• Are there any recent or pending insurance claims?

  Yes

  No

  N/A

• Please list any recent or pending insurance claims:

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