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My Senior
Solution Facility Search & Compare Form |
Use our
handy form when visiting different facilities. It's a great reference.
Print out and take with you. |
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Facility
1 ______________________________________ |
Location ___________________________________________ |
Phone ___________ |
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Facility
2 ______________________________________ |
Location ___________________________________________ |
Phone ___________ |
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Facility
3 ______________________________________ |
Location ___________________________________________ |
Phone ___________ |
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Facility 1 |
Facility 2 |
Facility 3 |
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Yes/No |
Yes/No |
Yes/No |
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1. Physical Structure |
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Facility presentable, in good repair
& kept up? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Is the
facility clean and neat? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Is the
facility quiet? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Are the
halls free of clutter? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Does it
have obvious odors? |
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_____/_____ |
_____/_____ |
_____/_____ |
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It the
temperature comfortable? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Residents regulate the heat in their room? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Is there
a disaster evacuation plan? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Are
there drills for disaster? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Safe area outside to sit in the
warm weather? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Is there
an area for activities? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Are the
resident rooms well ventilated? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Is there
daily housekeeping service? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Rooms conveniently located in
the facility? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Is there
sufficient closet space? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Is there
a bathroom close by? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Do hand grips for safety in the bathroom? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Is there
a call bell in the bathroom? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Is the
shower easy to get in and out of? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Are the
rooms comfortably furnished? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Is there
amenities such as a beauty shop or fitness area? |
_____/_____ |
_____/_____ |
_____/_____ |
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Is there
a smoking area? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Are
activities posted and age appropriate? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Do
residents participate in outings and social events? |
_____/_____ |
_____/_____ |
_____/_____ |
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Does the
facility provide assistance with bathing and grooming? |
_____/_____ |
_____/_____ |
_____/_____ |
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Does the
facility encourage involvement in community activities? |
_____/_____ |
_____/_____ |
_____/_____ |
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Is the
kitchen clean? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Doors to kitchen lock & medication areas? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Can
residents use the kitchen? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Is the
dining area pleasant and comfortable? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Can the
resident make a suggestion for dinner plan or snack?
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_____/_____ |
_____/_____ |
_____/_____ |
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Facility 1 |
Facility 2 |
Facility 3 |
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Yes/No |
Yes/No |
Yes/No |
| 2. Staff |
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Is the
home current with licensure/certifications and registration? |
_____/_____ |
_____/_____ |
_____/_____ |
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Does the
staff know the residents names? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Does the
staff take an interest and show respect to the residents? |
_____/_____ |
_____/_____ |
_____/_____ |
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Is there
a respect for resident privacy? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Do residents look clean, neat and cared for? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Do the
other residents look happy? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Is the
appearance of staff clean and neat? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Is there
enough staff per resident ratio? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Is there
a resident call bell system? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Is there
a nurse on staff or on call? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Facility control the residents
medications? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Facility make needed Dr
appointments? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Does the
facility have a transport system? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Staff trained in emergency care
or first aide? |
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_____/_____ |
_____/_____ |
_____/_____ |
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Facility
1 ______________________________________ |
Yes ________ |
No
________ |
Comments _____________________ |
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Facility
2 ______________________________________ |
Yes ________ |
No
________ |
Comments _____________________ |
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Facility
3 ______________________________________ |
Yes ________ |
No
________ |
Comments _____________________ |
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Form
Property of MySeniorSolution |
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