Volunteer Visit Report

 

Calendar

Nursing Home
Residential Care Facility
Assisted Living

IF YOU VISIT A MULTILEVEL FACILITY WITH A NURSING HOME, RESIDENTIAL CARE AND/OR ASSISTED LIVING, PLEASE COMPLETE A SEPARATE REPORT FOR EACH UNIT VISITED. IF REQUESTED TO VISIT A RESIDENT BY LTCOP STAFF, PLEASE COMPLETE A CASE INVESTIGATION REPORT.

PLEASE ASK IF THE FACILITY NEEDS ANY IN-SERVICE TRAINING.

minutes

minutes

minutes

(Check all that apply)

Routine visit to assigned facility
Quarterly monitoring visit
Participation in Survey
Family Council Meeting
Resident Council Meeting - (Please request an invitation to participate at least twice each year)

Observation Checklist and Action Taken

  No Yes N/A
Is facility free from unpleasant odors?
Does facility appear clean/uncluttered?
Are call bells working and within reach?
Are call bells answered in a timely manner?
Is the temperature in the facility comfortable?
Is the atmosphere friendly/welcoming?
Does staff have a pleasant attitude and freely interact with residents?
Are residents given privacy when care is being provided (i.e. bathing, toileting, etc.)
What are your observations about residents' appearances (i.e. clothing, hair, fingernails)? If there were concerns, please describe:
  No Yes N/A
Is the staffing ratio posted? (NF only)
Are bed rails in use or any restraint used?
If so, please explain.
(If Residential Care or Assisted Living, no full rails permitted, only 1/4 or 1/2 rails.)
  No Yes N/A
Is the LTCOP poster visible?
Is the menu posted?
Are there alternatives available?
If your visit was during a meal, what were your observations?
  No Yes N/A
Are residents given assistance with meals if needed?
Are footrests in use when a resident is transported in a wheelchair?
Is the activity calendar posted?
Are posted activities occurring?
What were residents engaged in during your visit?

Homeward Bound (NF only) - information/brochure provided:
(Enter the number of individuals in each category that received info/brochure)

Resident
Family Member
Staff Member
Resident Council Meeting Attendees

 

DO NOT SHARE INFO WITH THE FACILITY WITHOUT THE RESIDENT'S PERMISSION.

 

Did you follow up on a previous concern? If so, what was the result? Please include the resident's name.

 

During this visit were any new problems addressed or identified? If so, what action did you take? (Please use this space if you need to clarify anything from the observation checklist.)

 

IF ANY CONCERNS, PLEASE CALL THE OFFICE AT 1(800)499-0229. THANK YOU.

 

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"All long-term care consumers have the right to be treated with dignity and respect."