Form #2 Form #2 Assisted Living Provider Information Tool for Consumer E

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

ASSISTED LIVING PROVIDER INFORMATION TOOL
FOR CONSUMER EDUCATION
Developed by the Assisted Living Collaborative
This tool is intended for communities that meet the following definition of “assisted
living”:
“Assisted living” refers to residential long-term care options that are licensed, certified, or
registered by states as assisted living or other residential care names, such as board and care.
They combine housing and supportive services, which include at a minimum, assistance with
activities of daily living and/or health care (such as help with medication administration). Assisted
living settings have on-site staff available to meet both scheduled and unscheduled needs for
assistance 24 hours per day, seven days per week. They also offer dining (two or more meals
per day) and a variety of supportive services related to social and wellness activities. They care
for individuals with a range of functional needs including dementia, and may provide a dedicated
wing/area with additional security and cueing devices among other special services for those
individuals. Assisted living rooms/apartments may be offered in freestanding communities or in a
separate wing or building in a long-term care campus that provides other types of care.
For purposes of this tool, assisted living does not include residential long-term care options that
are licensed, certified, or registered by states as nursing homes, or to exclusively serve persons
with intellectual and developmental disabilities, mental illness (which is different than dementia),
or substance use disorders.
If your community does not meet this definition of assisted living, please do not complete
this tool. Instead, check this box and return the blank tool in the enclosed envelope: 

PRIVACY ACT STATEMENT: The information requested on this tool is being collected to assist the Agency for Healthcare Research and Quality (AHRQ)
and the Center for Excellence in Assisted Living in developing uniform information to help inform consumer decision making about assisted living residences.
The information you supply will be kept confidential to the extent permitted by law including AHRQ’s confidentiality statute, 42 USC 299c-3(c). The law
requires that information collected for research conducted or supported by AHRQ that identifies individuals or establishments be used only for the purpose for
which is was supplied unless you consent to the use of information for another purpose.
PAPERWORK REDUCTION ACT INFORMATION: Public reporting burden for this collection of information is estimated to average 25 minutes per
response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX)
AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

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While completing this tool, please consider the following information:


This information tool should take approximately 25 minutes to complete.



This tool should be completed by the individual who is the most knowledgeable about the
community’s operations, most typically, the Administrator or Executive Director. If the individual
completing the tool is not the most knowledgeable, it is advisable if other staff review the
responses to ensure they are correct.



The items on this tool relate only to your assisted living community and the assisted living
rooms/apartments, even though some assisted living communities include nursing home or
independent living rooms/apartments.



Answer the questions in reference to your entire assisted living community unless otherwise
instructed. Some assisted living communities offer specialized care, such as dementia care. If
your assisted living community offers more than one type of assisted living care (e.g., a portion of
the community that is set aside for dementia care), answer the questions in reference to the entire
community, unless otherwise instructed.



All questions should be completed in reference to current operations, as of the date the tool is
completed.



Complete these questions only in reference to the community located at the address to which this
tool was mailed. If you or your organization owns or operates more than one assisted living
community, complete the information tool in reference to the community identified in the mailing
address. If the address to which this tool was mailed is not the correct address for one of your
organization's assisted living communities, please call 1-XXX-XXX-XXXX to clarify this matter.



Your responses to this tool are provided voluntarily and all of your answers will be kept confidential.
If you have any questions about this tool, please call _______ at 1-XXX-XXX-XXXX.



Please place an “X” over the circle to indicate your answer, like this:
If you are unsure about how to answer a question, please give the best answer you can.


Please answer each question unless you are asked to skip to another question.



Select only one answer for each question unless you are asked to “Indicate all that
apply”.



It is best to use a soft lead pencil in case you want to change an answer.



When you are finished, please place the tool in the enclosed postage-paid envelope
and put it in the mail.

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2

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX
Estimated burden: 25 minutes

Abt SRBI ID # XX-XXX

minutes

A. Description of Assisted Living Community
A1. Please answer these descriptive questions about your assisted living community:

| | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Address: | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
City: | | | | | | | | | | | | | | | | | | | | State: |
Zip: | | | | |
County: | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Telephone Number: (
| | )| | | | - | | | | .

a. Community Name:

b.
c.
d.
e.

A2. a. Does your community have a website?
O Yes  What is the website address?

| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
O No
b. Does your community have an e-mail address to which prospective residents and families
can send comments and questions?
O Yes  What is the e-mail address?

| | | | | | | | | | | | | | | |

| | | | | | | | | | | | | | | | | |

O No
A3. Is your community licensed/registered/certified by the state to provide residential and
supportive services?
O Yes
O No
A4. Which of these categories describes your community’s ownership? SELECT ONE ANSWER
O For profit
O Not for profit
O City/county/state government
O Other  Specify: ___________________________________________________________
A5. This question asks about resident rooms/apartments. A room/apartment is the area dedicated
to the use of one or more residents, set off from common spaces by a door. So, if an
apartment is set off from the common space by a door, it counts as one room/apartment, even
if the apartment itself has more than one room. How many assisted living rooms/apartments
are in your community?
Number of rooms/apartments:
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| | | |
3

A6. Do all of your assisted living rooms/apartments have these features?
SELECT ONE ANSWER FOR EACH ROW
a. A private toilet
b. A private shower or bathtub
c. An entry door that locks

Yes
O
O
O

No
O
O
O

A7. Does your assisted living community have a dementia neighborhood or unit (whether or not it
is locked), meaning all or a section of the building that is dedicated to serving persons with
Alzheimer’s Disease and other dementias?
O Yes
O No
A8. Are the following types of services provided at the same location (same
address or campus), regardless of whether or not it is in the same building?
SELECT ONE ANSWER FOR EACH ROW
a. Independent living/independent apartments
b. Nursing home beds
c. Hospital
d. Other  Specify:
_______________________________________________________________

Yes
O
O
O
O

No
O
O
O
O

A9. Is your assisted living community part of a continuing care retirement community (CCRC)?
O Yes
O No
B. Move In and Move Out Processes
These questions ask about the move in and move out processes used by your community.
Many assisted living communities collect a variety of different fees during the move-in process.
While the names used for these vary from place to place, the next few questions are designed to
obtain information on what your community does in this regard.
B1. Does your community require these for move-in?
SELECT ONE ANSWER FOR EACH ROW
a. A reservation fee to be on a waiting list or to reserve a
room/apartment
b. A one-time, partially refundable or non-refundable entrance
or community fee
c. A security deposit to cover damages
d.. Other deposits (e.g., pets, smoking)
e. Last month’s “rent”

Yes
O

No
O

Sometimes
O

O
O

O
O

O
O

O
O
O

O
O
O

O
O
O

B2. Does your community require a resident to have a recent medical evaluation (by a nurse or physician)
as part of the move-in process?
O Yes
O No

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B3. The following questions ask about whom you accept to move in, and whom you will retain in
your community. For each of the areas, please indicate:
(1) If your community generally allows a person to move in who routinely needs staff
assistance (such as one-on-one monitoring or physical assistance) in that area; and
(2) If your community generally retains a resident who routinely needs staff assistance (such
as one-on-one monitoring or physical assistance) in that area.
SELECT ONE ANSWER FOR QUESTION (1) AND ONE ANSWER FOR QUESTION (2) FOR EACH ROW
(1) Will your community
generally allow a
person to move in who
routinely needs staff to
assist with…

a. Evacuating in an emergency O Yes
O No
O No, state prohibits
b. Toileting

O Yes
O No
O No, state prohibits

c. Incontinence care (bladder)

O Yes
O No
O No, state prohibits

d. Incontinence care (bowel)

O Yes
O No
O No, state prohibits

e. Bathing

O Yes
O No
O No, state prohibits

f. Dressing

O Yes
O No
O No, state prohibits

g. A two-person transfer
between bed and chair or
wheelchair

O Yes
O No
O No, state prohibits

h. Transferring from bed to
chair or wheelchair (but less
than a two-person transfer)

O Yes
O No
O No, state prohibits

i. Eating (such as cutting up
food or providing special
set-up or devices)

O Yes
O No
O No, state prohibits

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(2) Will your community generally retain a
resident who routinely needs your staff to
assist with…

O Yes
O Maybe, with outside services and/or other
special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or other
special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or other
special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or other
special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or other
special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or other
special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or other
special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or other
special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or other
special circumstances
O No, requires discharge

5

(1) Will your community
generally allow a
person to move in who
routinely needs staff to
assist with…

(2) Will your community generally retain a
resident who routinely needs your staff to
assist with…

j. Dining (hands-on assistance
with eating)

O Yes
O No
O No, state prohibits

O Yes
O Maybe, with outside services and/or other
special circumstances
O No, requires discharge

k. Care of Stage 1 or 2
pressure sores

O Yes
O No
O No, state prohibits

l. Oxygen that needs a nurse
or other trained staff to
calibrate/manage

O Yes
O No
O No, state prohibits

m. PRN (as needed)
medications

O Yes
O No
O No, state prohibits

n. Injectable medications such
as insulin

O Yes
O No
O No, state prohibits

o. An indwelling catheter

O Yes
O No
O No, state prohibits

p. Tube feeding

O Yes
O No
O No, state prohibits

O Yes
O Maybe, with outside services and/or other
special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or other
special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or other
special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or other
special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or other
special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or other
special circumstances
O No, requires discharge

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B4. These next items ask:
(1) If your community generally allows people with the following needs to move in; and
(2) If your community generally retains a resident with the following needs.
SELECT ONE ANSWER FOR QUESTION (1) AND ONE ANSWER FOR QUESTION (2) FOR EACH ROW
(1) Will your community
generally allow a person
to move in who…

a. Uses oxygen which the
resident can manage
him/herself

O Yes
O No
O No, state prohibits

b. Administers his/her own
injectable medication, such
as insulin

O Yes
O No
O No, state prohibits

c. Is enrolled in Hospice

O Yes
O No
O No, state prohibits

d. Has poor safety awareness
(for example, wanders or
requires constant
supervision)

O Yes
O No
O No, state prohibits

e. Exhibits difficult or disruptive
behaviors

O Yes
O No
O No, state prohibits

f. Has a primary diagnosis of
an intellectual or
developmental disability
(e.g., Down’s Syndrome)

O Yes
O No
O No, state prohibits

g. Has a primary diagnosis of
a psychiatric disorder, other
than Alzheimer’s disease or
other dementia

O Yes
O No
O No, state prohibits

h. Uses a Hoyer or other
mechanical lift for
transferring

O Yes
O No
O No, state prohibits

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(2) Will your community generally retain a
resident who. . .

O Yes
O Maybe, with outside services and/or
other special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or
other special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or
other special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or
other special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or
other special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or
other special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or
other special circumstances
O No, requires discharge
O Yes
O Maybe, with outside services and/or
other special circumstances
O No, requires discharge

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C. Service Provision
C1. Please indicate how your community’s recurring monthly fees are set. INDICATE ALL THAT
APPLY.
O Number of different services that are grouped together in tiers
O Fees for specific services (a la carte pricing)
O Minutes for specific services, such as the amount of time required to assist with dressing
O Points for specific services, such as based on the need for assistance with dressing
O Other
O None of the above, community has an all-inclusive flat rate with no additional charges
C2. For each of these services, please indicate whether it is:
 offered; part of the basic package (base rate) of services; or
 offered; may be an additional fee; or
 not offered
SELECT ONE ANSWER FOR EACH ROW
a. Personal care and assistance
(1) For dressing and grooming
(2) For mobility (walking and wheelchair use)

Offered,
basic
package

Offered,
may be an
additional
fee

Not
offered

O
O

O
O

O
O

O

O

O

O

O

O

O

O

O

(6i) For bathing twice a week or less

O

O

O

(6ii) For bathing more than twice a week

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O
O
O
O

O
O
O
O

O
O
O
O

O

O

O

O

O

O

O

O

O

O

O

O

(3) For transferring (bed to chair or wheelchair)
(4) For eating, such as cutting food or providing special set-up or
devices
(5) For dining (hands-on assistance with eating)

b. Toileting and incontinence care
(1) Reminders, assistance, and supervision with toileting
(2) Managing supplies, assisting in use of supplies, doing related
cleaning and laundry
(3) Assistance with catheter care
(4) Assistance with ostomy care
c. Housekeeping at least weekly, including vacuuming, emptying
trashcans, cleaning the bathroom, and changing the bed
d. Linen service (bed linen and towels) at least weekly,
e. Personal laundry (clothing) at least weekly
f. Meals available at non-scheduled times
g. Prescribed and special diets, such as diabetic ormechanical
soft
h. Health care services
(1) Regularly scheduled assessment of resident health, function,
and cognition by a licensed nurse (RN, LPN, LVN) after
move-in
(2) Assessment of skin integrity by a licensed nurse as needed
(3) Vital sign/wellness monitoring, such as blood pressure,
weight, pulse, temperature, respiration
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C2. For each of these services, please indicate whether it is:
 offered; part of the basic package (base rate) of services; or
 offered; may be an additional fee; or
 not offered
SELECT ONE ANSWER FOR EACH ROW
(i) at least monthly
(ii) more often than monthly
(4) Finger stick glucose testing as needed
(5) Oxygen use/equipment management
i. Medications
(1) Staff set-up medications in pill organizers
(2) Staff prepare medications such as mixing, crushing, or
dissolving medications
(3) Staff pass medications
(4) Staff give injections
j. Transportation for medical appointments
(1) During designated times only
(2) As requested
(3) With an escort
(4) Within a set distance
(5) Beyond a set distance
k. Transportation for non-medical reasons, such as to
social/cultural/religious activities
(1) During designated times only
(2) As requested
(3) With an escort

Offered,
basic
package

Offered,
may be an
additional
fee

Not
offered

O
O

O
O

O
O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O
O
O

O
O
O

O
O
O

O

O

O

O

O

O

O
O

O
O

O
O

C3. Does your community have contracts or established arrangements with the
following professionals to visit and provide services to residents on-site?
SELECT ONE ANSWER FOR EACH ROW
a. Physician, nurse practitioner, or physician’s assistant
b. Podiatrist
c. Dental hygienist
d. Dentist
e. Optometrist
f. Audiologist
g. Physical, occupational, or speech therapist
h. Licensed clinical mental health provider

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Yes
O
O
O
O
O
O
O
O

No
O
O
O
O
O
O
O
O

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C4. The next questions relate to recreational services, support/education, and
social setting:
SELECT ONE ANSWER FOR EACH ROW
a. Does your community provide scheduled group activities
(1) at least twice a day during the week?
(2) at least twice a day on weekends?
b. Does your community develop individualized activity plans?
c. Does your community have resident support/education groups related to wellness,
managing chronic health conditions such as dementia or diabetes, or other
topics?
d. Does your community have family support/education groups related to wellness,
managing chronic health conditions such as dementia or diabetes, or other
topics?
e. Does your community have a resident council?
f. Does your community have a family council?
g. Does your community provide personal mailboxes for each resident?
h. Does your community have any community pets (such as dogs, cats, rabbits, fish,
or birds) meaning pets whose care is not the responsibility of an individual
resident?
C5. Which of these activities does your community offer, either
to the community at large and/or designed for residents with
dementia?
INDICATE ALL THAT APPLY FOR EACH ROW

a. Spiritual/religious
b. Physical activity, such as weight-lifting, swimming, yoga, or
Wii Sports
c. Music activity/therapy
d. Tactile and sensory-related activities
e. Reminiscence

Yes

No

O
O
O

O
O
O

O

O

O

O

O
O
O

O
O
O

O

O

Yes,
designed
for
Yes,
offered to residents
community
with
at large
dementia

Not
offered
at all

O

O

O

O

O

O

O
O
O

O
O
O

O
O
O

D. Policies

D1. These questions relate to medications:
SELECT ONE ANSWER FOR EACH ROW
a. Is an assessment done (by your staff or someone else) regarding a resident’s ability
to self-administer medications independent of staff assistance?
b. Does your community or state prohibit all residents from keeping prescribed
medications in their rooms?
c. Does your community or state prohibit all residents from keeping over-the-counter
medications in their rooms?
d. Does your community or state prohibit all residents from self-administering their
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Yes

No

O

O

O

O

O

O

O

O

10

prescribed medications independent of staff assistance?
e. Does your community or state prohibit all residents from self-administering their
over-the-counter medications independent of staff assistance?
f. Does your community offer regular review of medications by a nurse or pharmacist?
g. If a resident wants to use a pharmacy other than those with which you contract, will
you help coordinate this?
IF YES: (1) Is there an additional fee for arranging this individualized service?
(2) Do these restrictions apply?
(a) Pharmacy must package medications in accordance with community
packaging requirements
(b) Delivery of medication must be available on an emergency basis
D2. Does your community or state prohibit all residents from:
SELECT ONE ANSWER FOR EACH ROW
a. Smoking?
(1) in rooms/apartments
(2) in designated areas in the building
(3) on the grounds
b. Keeping/consuming alcoholic beverages in their rooms?
c. Consuming alcoholic beverages in common areas, such as the dining room?
d. Keeping a cat, dog, or other pet in their room/apartment?

D3. Does your community have a written policy in these areas?
SELECT ONE ANSWER FOR EACH ROW
a. Resident rights (as per state law)
b. Fire evacuation plan
c. Emergency plan
d. Missing person or elopement policy
e. Involuntary discharge procedures including appeals
f. Community’s rules
g. Grievance procedures
h. Advance directives
j. Restraints and restraint alternatives
k. Visitation, such as who can visit or related to visiting hours or overnight guests
l. Conjugal visits

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O
O

O
O

O

O

O

O

O

O

O

O

Yes

No

O
O
O
O
O

O
O
O
O
O

O

O

Yes
O
O
O
O
O
O
O
O
O
O
O

No
O
O
O
O
O
O
O
O
O
O
O

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E. Charges and Payments
Some assisted living communities offer different types of rooms/apartments as well as private and
shared rooms.
E1. For each type of room/apartment that your community has, whether in a dementia
neighborhood or not, what is the (1) size, and (2) monthly rental fee if occupied by one person? If
you do not have that type of room/apartment, indicate N/A (not applicable).

a. 2 Bedroom apartment
(includes private bath and
kitchenette)

(1) Square footage (range)

(2) Monthly rental fee
(range)

____ sq. ft. to ____ sq. ft.

$______ to $______

____ sq. ft. to ____ sq. ft.

$______ to $______

____ sq. ft. to ____ sq. ft.

$______ to $______

____ sq. ft. to ____ sq. ft.

$______ to $______

____ sq. ft. to ____ sq. ft.

$______ to $______

O N/A
B. 1 Bedroom apartment
(includes private bath and
kitchenette)
O N/A
c. Studio/Efficiency
room/apartment (includes
private bath and kitchenette)
O N/A
d. Private room (excludes
kitchenette, includes private
bath)
O N/A
e. Private room (excludes
kitchenette and bath)
O N/A

Note: Monthly rental fee may include some supportive and/or health-related services. This information is
asked earlier in Section C.

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E2. For a semi-private room (a room shared by two strangers and with no kitchenette), what is the
(1) room size and (2) the per person monthly rent?

a. Semi private room
(excludes kitchenette)

(1) Square footage (range)

(2) Monthly rental fee
(range)

____ sq. ft. to ____ sq. ft.

$______ to $______

O N/A

The next questions are about public payment.
E3. Regarding public payment:
SELECT ONE ANSWER FOR EACH ROW
a. Does your community accept Medicaid for prospective (i.e., newly moved in)
residents?
Medicaid may have another name in some states, such as Medi-Cal,
MassHealth, Oregon Health Plan, or TennCare.
b. Does your community accept Medicaid for existing residents who have spent
down?
c. Is there generally a wait list for residents with Medicaid?
d. Does your community accept other public assistance, such as Veterans Aid
and Attendance or state-funded subsidies?

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Yes

No

O

O

O

O

O

O

O

O

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F. Staffing
The next questions ask about nurse staffing (RNs, LPNs, LVNs) in your community. Indicate all
that apply.

F1. How often does your community use registered nurse(s
(RNs)? INDICATE ALL THAT APPLY
a. IF ON-SITE: Does your community staff fewer RNs
during the weekends than during the week?
O Yes
O No
F2. How often does your community use licensed practical
nurse(s) (LPNs) or licensed vocational nurse(s)
(LVNs)? INDICATE ALL THAT APPLY
a. IF ON-SITE: Does your community staff fewer
LPNs/LVNs during the weekends than during the
week?
O Yes
O No

Onsite
24/7

On-site
at least
35
hrs/wk

On-site
less
than 35
hrs/wk

On
call

Do
not
use

O

O

O

O

O

O

O

O

O

O

The next questions are about the nurses and other care staff in your community.
SELECT ONE ANSWER FOR EACH ROW
F3. Is at least one staff member (personal care assistant, or CNA, or RN, or LPN, or
LVN):
a. On-site 24 hours a day, 7 days a week?
b. Required to be awake at all times?
F4. Does your community have a Medical Director?
F5. Does your community require criminal background checks for all new employees?
F6. Does your community have someone on staff who is professionally trained (such as a
social worker) to help families and residents deal with psychosocial issues such as
challenges of aging, transitions to and within the community, and dementia?
F7. These questions relate to staff training. Please indicate
which staff receives training in the following areas:
INDICATE ALL THAT APPLY FOR EACH ROW
a. Resident care and services (such as ADL care, rights and
responsibilities, abuse and neglect, confidentiality,
transitions of care)
b. Safety (such as food handling and safety, infection control,
first aid/CPR, fire emergency and preparedness)
c. Age-related changes (such as incontinence, falls,
malnutrition, hearing/vision, thinning bones, sleep
problems)
d. Dementia (such as person-centered caring, communication
training, behavior management, psycho-social needs of
population)
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Personal
care
assistants,
CNAs
RN/LPN/LVN

Yes

No

O
O

O
O

O

O

O

O

O

O

Other
staff

No
staff

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

14

e. Service delivery practices (such as communication
training, team building, person-centered care, cultural
competency, customer service, family support)
f. Medication management (such as types of administration,
storage, documentation, re-ordering)
g. Palliative and end-of-life care (such as advance directives,
pain control, and grief and loss)

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O

O

O

O

O

O

O

O

O

O

O

O

15

G. Environment
The next questions ask about different components of your community’s
environment.
SELECT ONE ANSWER FOR EACH ROW
G1. Do residents live on three or more floors (also known as stories) in your
building?
G2. Is the front door secured by a keypad or other safety locking device that
prevents persons at risk of elopement from leaving?
G3. Does your community have these common spaces available for use by
residents and families?
a. A private dining room
b. A kitchen
c. A secure outdoor space for activities
d. A designated smoking area
G4. Does your community have special environmental adaptations for residents
who are blind or have low vision, such as contrasting color walls and
carpeting, large-button telephones, or oversized clocks?
F5. EXCLUDING A DEMENTIA CARE NEIGHBORHOOD, does your
community have some physical design features for persons with dementia,
such as short corridors, contrasting colors, or environmental cues?

Yes

No

Not
applicable

O

O

O

O

O

O

O

O

O
O
O

O
O
O

O
O
O

O

O

O

O

O

O

O

G6. For each of these, does your community:


offer it as part of the basic package (base rate) of services; or
 offer it for an additional fee (not part of the basic package); or
 not offer it

a.
b.

c.

d.

SELECT ONE ANSWER FOR EACH ROW
Complete room furnishings, including furniture and window
covering
Local telephone service
(1) in common areas
(2) in apartments/rooms
Cable or satellite TV
(1) in common areas
(2) in apartments/rooms
Internet access
(1) hard-wired, in common areas
(2) hard-wired, in apartments/rooms
(3) wireless internet (WiFi) throughout the building

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Offered,
basic
package

Offered,
additional
fee

Not
offered

O

O

O

O
O

O
O

O
O

O
O

O
O

O
O

O
O
O

O
O
O

O
O
O

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The next items are about life safety and accessibility of different safety features.
G7. Does your community have …
Yes, in
No
SELECT ONE ANSWER FOR EACH ROW
some
a. A sprinkler system in resident rooms and apartments
O
O
b. A sprinkler system in common areas
O
O
c. A smoke detector in resident rooms and apartments
O
O
d. A smoke detector in common areas
O
O
e. A carbon monoxide detector in targeted areas
O
O
f. An emergency call or personal response system available in resident
O
O
rooms and apartments

G8. Does your community have a fire alarm system that is …
SELECT ONE ANSWER FOR EACH ROW
a. Tied to the fire department
b. Adapted for people who are deaf or hard of hearing, such as flashing
lights
c. Adapted for people who are blind or have low vision, such as auditory
alarms

Yes, in
all
O
O
O
O
O
O

No
O

Yes, in
some
areas
O

Yes,
in all
areas
O

O

O

O

O

O

O

G9. Who provides the furniture for the resident’s apartment? SELECT ONE ANSWER
O Residents must bring all of their own furniture (all rooms/apartments are unfurnished)
O Residents may either bring their own furniture or use furniture provided by the community
O Residents must use the community furniture but may bring small pieces of furniture such as a
chair or dresser
O Residents must use the community furniture and may not bring any furniture

G10. Are these areas accessible
(meaning able to be entered and
used) for residents who use
(1) manual walkers or wheelchairs,
(2) power wheelchairs or scooters?
SELECT ONE ANSWER FOR QUESTION
(1) AND ONE ANSWER FOR QUESTION
(2) FOR EACH ROW

a. Rooms/apartments
b. Resident bathrooms
c. Common dining rooms
d. Other common areas, such as living
rooms

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(1) For people who use a
manual walker or
wheelchair?

No

Yes,
some
areas of
the
building

Yes, all
areas in
the
building

O
O
O

O
O
O

O

O

(2) For people who use a power
wheelchair or scooter?

No

Yes,
some
areas of
the
building

Yes, all
areas in
the
building

Not
permitted
in the
building

O
O
O

O
O
O

O
O
O

O
O
O

O
O
O

O

O

O

O

O

17

G11. This question applies only to communities that operate a dementia neighborhood -- meaning
all or a section of the building is dedicated to serving persons with Alzheimer’s Disease and
other dementias.
IF YOUR COMMUNITY DOES NOT HAVE A DEMENTIA NEIGHBORHOOD, CHECK THIS BOX
AND GO TO SECTION H: 

Regarding your dementia neighborhood,
SELECT ONE ANSWER FOR EACH ROW
a. Is the dementia neighborhood secured by a keypad or other safety locking device
that prevents persons at risk of elopement from leaving?
b. Does the dementia neighborhood have some physical design features for persons
with dementia, such as short corridors, contrasting colors, or environmental cues?
c. Do residents in the dementia neighborhood have:
(1) access to a common space dedicated to dining?
(2) access to one or more common spaces dedicated to activities?
(3) access to a secure outdoor space for activities?
(4) access to a designated smoking area?

Yes

No

O

O

O

O

O
O
O
O

O
O
O
O

H. Closing Questions
H1. If there is something distinctive about your community or services that would be helpful for
consumers to know, please indicate it here:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
H2. What is/are the position(s) of the person(s) completing this form (such as Administrator,
Executive Director, Regional Director)?
________________________________________________________________________________
________________________________________________________________________________
. H3 What is the date this form was completed?

m |m / d |d / y |y.

Thank you for providing this information!
Please return this completed form in the enclosed postage-paid envelope to:
Abt SRBI Inc.
55 Wheeler Street Cambridge, MA 02138

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