Form Cms-806a - Quality Of Life Assessment - Resident Interview (Page 2 of 4) in pdf

Form Cms-806a - Quality Of Life Assessment - Resident Interview Page 2

RESIDENT INTERVIEW

2. ENVIRONMENT: (F252, 258)

Is there anything that would make this facility more

I realize that being in a nursing home is not like being in

comfortable for you?

your own home, but do staff here try to make this

Is it generally quiet or noisy here?

facility seem homelike?

What about at night?

We've already talked about your room. How about other

Is the facility usually clean and free of bad smells?

places you use, like the activities room and dining

room? Do they seem homelike to you?

3. PRIVACY: (F164, 174)

(If no phone in room) Where do you make phone calls?

Are you a person who likes to have privacy sometimes?

Do you have privacy when you are on the phone? (If the

Are you able to have privacy when you want it?

resident indicates any problems with privacy, probe for

Do staff and other residents respect your privacy?

specific examples. Ask if they talked to staff and what

Do you have a private place to meet with visitors?

was their response.)

4. FOOD: (F365)

Have you ever refused to eat something served to you?

Tell me about the food here.

(If yes) Did the facility offer you something else to

Do you have any restrictions on your diet?

eat?

How does your food taste?

(If the resident refused a food and did not get a

Are you served foods that you like to eat?

substitute) Did you ask for another food? What

Are your hot and cold foods served at a temperature

was the facility's response?

you like?

5. ACTIVITIES: (F242, 248)

(If resident does not participate, probe to find out why

How do you find out about the activities that are going

not.)

on?

Is there some activity that you would like to do that is

Are there activities available on the weekends?

not available here?

Do you participate in activities?

(If yes) Which activity would you like to attend?

(If yes) What kinds of activities do you participate in?

Have you talked to anybody about this? What was

(If resident participates) Do you enjoy these activities?

the response?

Form CMS-806A (07/95)

Form Cms-806a - Quality Of Life Assessment - Resident Interview Page 2

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