Site Assessment Profile

The following items provide an operational profile of your nursing home or department.
Please provide information on as many items as are applicable.

1.1 Name of nursing home:  _______________________________________________________________

1.2 Date this survey completed:  _____________________________________________________________

1.3 Number of licensed beds:  ______________________________________________________

1.4 Annual census:  __________________________________________________________

1.5 Staff Profile: Check if for facilitywide  __________  or department  __________

Complete for the following:

1.6 Support Services (check all that apply)

1.7 Are there impending changes or initiatives that your facility is expecting in the next 12 months? (Check all that apply)

1.8 Overall Vision for the nursing home (may provide Mission, Vision, and Values):
        ________________________________________________________________________
        ________________________________________________________________________
        ________________________________________________________________________
 

1.9 What are the nursing home's strategic goals?
        ________________________________________________________________________
        ________________________________________________________________________
        ________________________________________________________________________
 

1.10   Has a Resident Care Team Training initiative ever been conducted in your nursing home?

Yes or No. If yes, what was the impact and are teams still functional (list departments)?

        ________________________________________________________________________
        ________________________________________________________________________
        ________________________________________________________________________
        ________________________________________________________________________
        ________________________________________________________________________
 

1.11 What clinical and safety measures are you currently tracking?
        ________________________________________________________________________
        ________________________________________________________________________
        ________________________________________________________________________
        ________________________________________________________________________
 

1.12 Resident Satisfaction Surveys:

1.12a What resident satisfaction tool does your site currently use?
  ________________________________________________________________________
  ________________________________________________________________________
  ________________________________________________________________________

1.12b What do residents report being most satisfied with?
  ________________________________________________________________________
  ________________________________________________________________________
  ________________________________________________________________________

1.12c What do residents report being least satisfied with?
  ________________________________________________________________________
  ________________________________________________________________________
  ________________________________________________________________________

1.12d Please provide most recent reported measures:
  ________________________________________________________________________
  ________________________________________________________________________
  ________________________________________________________________________

1.13 Family Satisfaction Surveys:

1.13a What tool do you currently use to assess family satisfaction?
  ________________________________________________________________________
  ________________________________________________________________________
  ________________________________________________________________________

1.13b What do families report being most satisfied with?
  ________________________________________________________________________
  ________________________________________________________________________
  ________________________________________________________________________

1.13c What do families report being least satisfied with?
  ________________________________________________________________________
  ________________________________________________________________________
  ________________________________________________________________________

1.13d Please provide most recent reported measures:
  ________________________________________________________________________
  ________________________________________________________________________
  ________________________________________________________________________

1.14 Staff Satisfaction Surveys:

1.14a What tool do you currently use to assess staff satisfaction?
  ________________________________________________________________________
  ________________________________________________________________________
  ________________________________________________________________________

1.14b What do staff report as the most satisfying part of their job?
  ________________________________________________________________________
  ________________________________________________________________________
  ________________________________________________________________________

1.14c What do staff report being least satisfied with?
  ________________________________________________________________________
  ________________________________________________________________________
  ________________________________________________________________________

1.14d Please provide most recent reported measures:
  ________________________________________________________________________
  ________________________________________________________________________
  ________________________________________________________________________

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