Navigating through the complex landscape of assisted living requires meticulous documentation and assessment to ensure that the needs of each resident are met with the utmost care and attention. The Living Assessment form, a critical tool in this process, is designed to facilitate a comprehensive evaluation of a resident's abilities and needs within an assisted living facility. Completed by the Assisted Living Manager or their appointed designee, this form covers a broad range of areas including Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), behavior and communication patterns, eating habits and food preferences, as well as social and recreational needs. Key sections of the form assess a resident's capability in areas such as mobility, personal care, meal preparation, housekeeping, and financial management. Items marked with an asterisk serve as triggers to identify residents who may require awake overnight staff. The form also delves into the resident’s social support system, spiritual needs, education, work history, and recreational interests, providing a well-rounded picture of the individual's life and needs. By meticulously recording scores and observations, the form aids in tailoring the care provided to each resident, ensuring that assistance is geared towards promoting independence while providing necessary support.
| Question | Answer |
|---|---|
| Form Name | Form Living Assessment |
| Form Length | 5 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 15 sec |
| Other names | living assisted assessment, skilled nursing assessment forms, assisted living resident assessment form, assisted living forms |
1
Resident Name __________________________________ |
Date Completed ______________________ |
Date of Birth ____________________________________ |
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Assisted Living Manager’s Assessment
This form is to be completed by the Assisted Living Manager or their designee. Questions noted with an asterisk are “triggers” for awake overnight staff.
Instructions: Record score in the blank next to each question.
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Activities of Daily Living |
13.* |
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Resident Eats |
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0 |
Independently |
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1 |
With supervision, or |
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2 |
With physical assistance or use of adaptive devices, such as built up utensil, plate guard, or |
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*3 Must be fed or needs tube feeding |
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14.* |
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Resident’s Mobility (moves from place to place) |
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0 |
Independently |
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1 |
With supervision, or |
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*2 |
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*3 |
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15.* |
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Resident Transfer to Bed, Chair, or Toilet |
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0 |
Independently (or with assistive device) |
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1 |
With supervision, or |
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*2 |
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*3 |
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16.* |
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Bed Mobility (how resident moves to and from lying position, turns side to side, and positions body |
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while in bed) |
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0 |
Independently (or with assistive device) |
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1 |
With supervision, or |
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*2 |
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*3 |
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17.* |
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Resident Use of Stairs |
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0 |
Independently (or with assistive device) |
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1 |
With supervision, or |
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2 |
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3 |
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18.* |
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Resident Continence |
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0 |
Independently |
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*1 With supervision, or |
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*2 Needs physical assistance from one other person
*3 Incontinent, needs complete assistance
19.Resident Completes Bathing 0 Independently
1 With supervision, or
2 Needs physical assistance (e.g., help in and out of tub, washing hair)
3 Must be bathed, needs complete assistance or mechanical assistance (e.g., Hoyer Lift)
20.Resident Completes Grooming (teeth,
1 With supervision, or
3 Must be groomed, needs complete assistance
Form 4506 Revised
2
Resident Name __________________________________ |
Date Completed ______________________ |
Date of Birth ____________________________________ |
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21.Resident Gets Dressed/Changes Clothes 0 Independently
1 With supervision, or
3 Must be dressed, needs complete assistance
21(a) |
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Add scores for Items 13 - 21. Enter total in blank space at left. |
Instrumental Activities of Daily Living
Note: Incapacities identified in this section do not imply services will be provided.
Instructions: Check the letter that most closely reflects the resident’s capabilities.
22.Resident Can Prepare Light Meal
A – Independent, plans and prepares adequate meals
B – With supervision,
C –
D – Unable to prepare meals
23.Resident Can Do Light Chores
A – Independent
B – With supervision,
C –
D – Unable to do light chores
24.Resident Can Do Shopping
A – Independent
B – With supervision or cuing and coaching (e.g., choosing items)
C – With
D – Unable to do shopping
25.Ability to Manage Finances
A – Family or resident manages all financial matters independently, writes checks, pays bills/rent, goes to bank
B – With supervision, writes checks, pays bills/rent, goes to bank
C – Manages
26.Transportation
A – Travels by self, all modes of transportation
B – Needs some assistance/escort
C – Complete assistance/needs specialized vehicle
27.Resident Can Use Telephone
A – Independent
B – With assistance dialing/using directory
C – Unable to use telephone
Form 4506 Revised
3
Resident Name __________________________________ |
Date Completed ______________________ |
Date of Birth ____________________________________ |
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Behaviors/Communication
Does the resident exhibit any of the following behaviors? Check the appropriate box to indicate frequency of each behavior. For scoring purposes use the highest frequency noted. See the User’s Guide for definitions of frequency.
28.Withdrawn: Frequency of behavior(s) (check appropriate response):
A. |
Refuses to leave room |
Never |
Occasional |
B. |
Refuses to socialize with others |
Never |
Occasional |
Regular Regular
Continuous Continuous
Explain ________________________________________________________________________________________________
29.* Wanders: Frequency of behavior(s) (check appropriate response):
A. Persistent moving/walking about without purpose |
Never |
Occasional |
B. Looks for |
Never |
Occasional |
*C. Actively tries to leave facility |
Never |
Occasional |
D. Wanders during day |
Never |
Occasional |
*E. Wanders in evening and/or at night |
Never |
Occasional |
Regular
Regular
Regular*
Regular
Regular*
Continuous
Continuous
Continuous*
Continuous
Continuous*
Explain ________________________________________________________________________________________________
30.* Sleep disturbance: Frequency of behavior(s) (check appropriate response):
*A. Unable to sleep or agitated at night |
Never |
Occasional |
B. Frequently falls asleep during day |
Never |
Occasional |
Regular* Regular
Continuous* Continuous
Explain ________________________________________________________________________________________________
31.* Verbally inappropriate: Frequency of behavior(s) (check appropriate response):
A. Uses foul language |
Never |
Occasional |
Regular |
*B. Sounds angry and threatens others |
Never |
Occasional |
Regular* |
Continuous Continuous*
Explain ________________________________________________________________________________________________
32.* Disruptive behaviors: Frequency of behavior(s) (check appropriate response):
A.Yells
B.Demands attention without regard to others *C. Takes other’s possessions
*D. Socially inappropriate behaviors (e.g., disrobes, urinates, or defecates in public)
*E. Sexually inappropriate behaviors (e.g., unwanted touching, public masturbation)
Never
Never
Never
Never
Never
Occasional
Occasional
Occasional
Occasional
Occasional
Regular
Regular
Regular*
Regular*
Regular*
Continuous
Continuous
Continuous*
Continuous*
Continuous*
Explain ________________________________________________________________________________________________
33.* Combative behaviors: Frequency of behavior(s) (check appropriate response):
*A. Throws objects indiscriminately |
Never |
Occasional |
*B. Strikes out, kicks, or punches at others |
Never |
Occasional |
*C. Pinches, bites, spits at others, scratches, or pulls hair |
Never |
Occasional |
Regular*
Regular*
Regular*
Continuous*
Continuous*
Continuous*
Explain ________________________________________________________________________________________________
Form 4506 Revised
4
Resident Name __________________________________ |
Date Completed ______________________ |
Date of Birth ____________________________________ |
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34.* Resistive/uncooperative behaviors: Frequency of behavior(s) (check appropriate response):
A.Refuses to wash
B.Refuses to eat
C.Refuses to drink
*D. Refuses to care for self
E.Refuses to allow others to assist
F.Refuses medications
*G. Refuses to comply with safety advice
Never
Never
Never
Never
Never
Never
Never
Occasional
Occasional
Occasional
Occasional
Occasional
Occasional
Occasional
Regular
Regular
Regular
Regular*
Regular
Regular
Regular*
Continuous
Continuous
Continuous
Continuous*
Continuous
Continuous
Continuous*
Explain ________________________________________________________________________________________________
35.* Communication (check and/or explain appropriate response):
A.Communicates needs, ideas, & wishes *B. Unwilling to communicate needs/wishes
Unable* Never
Sometimes Able* |
Usually |
Always |
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Occasional |
Regular* |
Continuous* |
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Explain ________________________________________________________________________________________________
36.Eating patterns and food preferences (check all that apply):
Eats full meals |
Eats only two meals |
Eats small portions |
Finger foods |
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Eats only what they want, but maintains weight |
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Eats only when they want |
Supplements (type ordered) ____________________________________________ |
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Prefers: |
Fruit |
Vegetables |
Meats |
Snacks or snack foods |
Explain ________________________________________________________________________________________________
Daily Social and Recreational Needs
37.Resident Support System (check all that apply):
Resident has |
Legal representative for health care decisions |
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Family is local |
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Involved |
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Not involved |
Family lives out of area |
Involved |
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Not involved |
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Problems with family circumstances |
Yes |
No |
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Problems with personal relationships |
Yes |
No |
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Surrogate decision maker (family member/significant other)
Explain ________________________________________________________________________________________________
38.Spiritual needs and status ______________________________________________________________
_____________________________________________________________________________________
39.Education/Work History (check/complete all that apply):
Did not complete high school
Completed high school or GED
College
Lifetime or last occupation _______________________________________________________________
40.Interests/Hobbies: ____________________________________________________________________
Form 4506 Revised
5
Resident Name __________________________________ |
Date Completed ______________________ |
Date of Birth ____________________________________ |
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41.Activity Status (interest and ability to participate in, check and explain):
A. Structured and group activities |
Yes |
No |
Varies |
Explain _______________________________________________________________________________________________
B. |
Yes |
No |
Varies |
Explain _______________________________________________________________________________________________
42.Current Daily Routine (e.g., up in the morning, bedtime, normal sleep cycle prior to move in, meal time preferences)
43.Interest/participation in programs away from facility (e.g., Senior Centers, Adult Day Care, or Rehabilitation Programs)
Print Name of Person Completing Assessment: _____________________________________________________
Position of Person Completing Assessment: _______________________________________________________
Date Completed: ________________________________
______________________________________________
Signature of Person Completing Assessment
Form 4506 Revised