Facility Evaluation Checklist
Current Resident/Patient Status	Yes	No	Type of Resident/Patient Accepted	Yes	No
Ambulation
Ambulatory			Accept ambulatory
Non Ambulatory			Accept non-ambulatory
Bedridden			Accept bedridden
Physical Health Status
Hearing impairment			Hearing impaired
Visual impairment			Visually impaired
Wears dentures			Resident with dentures
Special diet			Resident with special diet
Substance abuse issue			Resident with substance abuse issue
Use of alchohol			Resident consumes alcohol
Use of cigarettes			Resident smokes
Bowel impairment			Resident is bowel incontinent
Bladder impairment			Resident is bladder incontinent
Paralysis			Resident is paralyzed
Continuous bed care			Resident requires continues bed care
Skin breakdown			Resident has history of skin breakdown
Mental Condition
Confused/disoriented			Resident is confused/disoriented
Inappropriate behavior			Resident with inappropriate behavior
Aggressive behavior			Resident with aggressive behavior
Sun downing behavior			Resident with Sun downing syndrome
Able to follow instructions			Resident not able to follow instructions
Depressed			Resident with depression
Suicidal/self abuse			Resident that is suicidal
Able to communicate needs			Resident not able to communicate needs
Able to leave facility unassisted			Resident not able to leave unassisted
Capacity for self-care
Able to bathe self			Unable to bathe self
Able to dress/groom self			Unable to dress/groom self
Able to feed self			Unable to feed self
Able to care for own toileting needs			Unable to toilet on own
Able to manage own cash resources			Unable to handle own cash resources

Facility Evaluation Checklist
Current Resident/Patient Status	Yes	No	Type of Resident/Patient Accepted	Yes	No
Health Conditions
Contagious/infectious disease			Resident with a contagious/infectious disease
Allergies			Reisdent with allergies
Pressure sores			Resident with pressure sores
Gastrostomy care			Resident with gastrostomy
Naso-gastric tubes			Resident wth a naso-gastric tube
Tracheotomies			Resident with tracheotomy
Totally dependent on other for all ADL's
Oxygen - gas and liquid			Resident on oxygen
IPPB MAchine			Resident uses IPPB machine
Colosomy/ileostomy			Resident has colostomy or ileostomy
Urinary catheter			Resident has a urinary catheter
Managed incontinence			Resident has managed incontinence
Contractures			Resident has contractures
Diabetes			Resident is a diabetic
Terminal Illness
Requires pallative care			Resident needs pallative care
Requires hospice care			Resident needs hospice care