Please describe the potential resident's bathing ability.

Independent in bathing

Resists bathing and needs to be encouraged and or assisted

Needs assistance in bathing

Please describe the potential resident's grooming needs

Is able to groom self and perform self hygiene without assistance

Needs assistance in grooming and self hygiene due to physical limitations

Needs assistance in grooming and self hygiene due to memory challenges

Needs total assistance to groom and perform self hygiene

Please describe the potential resident's medical needs

Self administers and manages their medications

Needs reminders for medications

Does not recognize medications and needs assistance with medications

Needs help with blood glucose monitoring and insulin

Needs physical assistance with medications due to physical limitations

Please describe the potential resident's mobility needs

Is safe ambulating with or without an assistive device

Needs assistance in mobility for transfers or ambulation

Cannot remember to call for help due to memory challenges

Has balance issues and has fallen in last 90 days

Needs total assistance for transfers

Cannot use assistive device due to memory challenges

Please describe the potential resident's dressing needs

Is able to select appropriate attire and dress themselves

Reminders to put on clean clothes or assistance in selection

Needs physical assistance to dress due to physical limitations

Needs physical assistance to dress due to memory challenges

Please share the potential resident's needs on a daily basis

Is able to manage daily schedule and routine

Needs a structured day because of wandering

Gets confused or frustrated easily and needs good prompts and cues

Exhibits poor judgement when it comes to safety

Needs occasional reminders about events or meals

Tends to isolate and needs regular reminders for meals and events

Please describe the potential resident's toileting needs

Is incontinent but able to change themselves or with slight assistance

Is incontinent and cannot remember to change

Needs assistance with toileting due to physical limitations

Total transfer to toilet and back or in changing

Please describe the potential resident's dietary needs

Goes to meals and dines with out cueing or assistance

Requires reminders for meals

Requires physical assistance for meals

Has to be assisted with dining as has trouble with utensils due to physical limitations

Has to be assisted with dining as has trouble with utensils due to memory issues

Who Should We Contact with More Information?