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Use this form to record your observations of the instructor-approved facility. You will be required to submit the completed form with the final learning team assignment in Week Five.

University of Phoenix Material

Facility Study Form

Use this form to record your observations of the instructor-approved facility. You will be required to submit the completed form with the final learning team assignment in Week Five.

Long-Term Care Facility Checklist

Part I: Basic Information

Name of long-term care facility

Anna Maria of Aurora Main Campus


889 North Aurora Road, Aurora, Ohio 44202



Cultural or religious affiliation, if any


  Yes No
1.     Is the facility Medicaid certified? Yes ____
2.     Is the facility Medicare certified? Yes ____
3.     Is private insurance accepted? Yes ____
4.    Are other forms of payment accepted? If so, what is accepted?

Yes the facility also will accept waiver assistance for the assisted living section. Also benefits from the VA will also be accepted.

 Part II: Licensure and Accreditation    
  Yes No
1.     Is the facility licensed by the Department of Public Health? Yes ____
2.     Is there a current license displayed in the facility? Yes ____
3.     Is the administrator licensed or certified according to state standards? Yes ____
4.     Does the facility hold any accreditations? Yes ____
5.     How long has this facility been in business? Is it part of a larger organization?
The facility has been family owned and operated for the last 52 years.
Long-Term Care Facility Checklist – Continued

 Part III: Staff 

Yes No
1.     Is there a registered nurse on duty during the day and a licensed practical nurse on duty at all times? Yes ____
2.     What are the hiring procedures and requirements for eligibility?

First a potential employee must fill out an application and undergo the interview process. If the individual is hired they will undergo a background check as well as a full physical with a drug screen. Once all that information is received by human resources and everything checks out the individual will attend orientation.

3.     How long has the current administrator been there?

The current administrator has been in place for the last 16 years.

4.     What is the staff-to-patient ratio during the day? At night? On weekends?

During the day the staff-to-patient ratio is approximately 8 to 1 and drops down at night to 10-12 to 1. Of course these numbers all depend on the unit the individual is working as each unit has different care levels meaning that the more care that the individuals are in need of the less the patient to staff ratio number is.



5.     How are staff trained? Is there ongoing training or development?

All staff must be STNA’s (State tested nursing assistance) with a valid liscense and not on the abuse registrey. Each year there are inservices that must be attended as well as continuing education courses that must be completed online. If the individual is a new employee they get approximately 3 weeks of hands on training by a supervisor as well as a restorative aide.


Part IV: Public Perception

  Yes No
1.     Does the facility have a good reputation? Yes ____
2.     Is the facility attractive? Well-maintained? Yes ____
3.     Does there appear to be positive interaction between staff and residents? Yes ____
4.     Do the residents appear content with their surroundings and quality of life? Yes ____
5.     Are visits allowed and/or encouraged at any time? Yes ____


 Long-Term Care Facility Checklist – Continued

 Part V: Other Concerns

Yes No
1.     Has the facility experienced any complaints or corrective actions? Are they willing to discuss past problems and how they were resolved? ____ No
2.     Do residents have a means of expressing their opinions and ideas, such as a council or organization? Yes ____
3.     Are there any survey reports and/or lists of resident rights posted? Yes ____
4.     (Your concern)

The only concern that I personally have is that activities do not seem that they last as long as the residents want them to. I know this is truly not a major concern however, many of the residents seem to just begin to enjoy themselves and it’s over.

5.     (Your concern)    
Additional comments    


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