Proceed with the interview questions below if you are comfortable that the resident is

Resident Interview Interviewer Interview Date Resident Room Preparation Resident interviews should be conducted in a private setting so the resident feels comfortable providing honest answers without fear of being overheard. Ask screening questions similar to the following: 1. Are you from around here, the area, etc.? 2. Tell me a little about yourself. 3. How long have you been here? 4. What is the food like here? Proceed with the interview questions below if you are comfortable that the resident is interviewable. A. Cognitive Status 1. Is the resident able to be interviewed? Interviewable t Interviewable Resident refused B. Choices 1. Do you choose when to get up in the morning? If No: What time do you get up? What time would you like to get up in the morning? N/A, the resident is independent with ADLs Copyright Providigm, LLC. 2017 Resident Interview - Page 1 of 14

2. Do you choose when to go to bed at night? If No: What time do you go to bed? What time would you like to go to bed? N/A, the resident is independent with ADLs 3. Do you choose how many times a week you take a bath or shower? If No: How many times a week do you get a bath or shower? How many times a week would you like to bathe? N/A, the resident is independent with ADLs 4. Do you choose whether you take a shower, tub, or bed bath? If No: What type of bathing are you receiving? What would you like to receive? If facility does not have a tub for resident use and indicates that resident has a choice to take a shower or a bed bath, code as Yes to prevent from triggering based on the absence of a tub. N/A, the resident is independent with ADLs 5. Can you have visitors anytime during the day or night? If No: what are the visiting restrictions? C. Dignity 1. Do staff treat you with respect and dignity? If No, Tell me some examples about when staff did not treat you with respect and dignity. (The focus of this question is how well staff interact with the resident.) Copyright Providigm, LLC. 2017 Resident Interview - Page 2 of 14

2. Does the leadership team treat you with respect? (skip to D) a. Does the leadership team share your expectations regarding your care and outcomes? D. Activities 1. Do you participate in the activity programs here? If no, ask why he/she doesn t participate. Residents are not required to participate in group activities; if resident prefers activities in-room or alone, mark N/A, does not wish to participate. N/A, does not wish to participate (Skip to 2) a. Do the activities meet your interests? For No responses, record the resident s preferred activities. b. Are the activities provided as often as you would like, including on weekends and evenings? 2. Does staff provide items so you can do activities on your own, like books or cards? N/A, family provides Copyright Providigm, LLC. 2017 Resident Interview - Page 3 of 14

3. Do you feel that your spiritual needs are being met? (skip to E) a. Are you comfortable practicing your faith in this facility? t Applicable b. Are you able to practice your faith, such as attending spiritual services, as often as you would like? t Applicable c. Has the chaplain contributed to your emotional or physical well-being? t Applicable E. Building and Environment 1. Is the building clean? 2. Do you have any problems with the temperature, lighting, noise or anything else in the building that affects your comfort? (Mark all that apply) Temperature Lighting ise Other identified issues ne of the above Ask for details about the cause of the discomfort (type, volume or time of noise; temp too hot or too cold, etc.) and record in the comments. 3. Do you feel comfortable in this facility? (skip to F) Copyright Providigm, LLC. 2017 Resident Interview - Page 4 of 14

a. Is the care team warm and welcoming? F. Participation in Care Plan The intent of this question is to ensure residents are informed of, and play a role in, decisions about their care. The focus is on communication between the resident and facility caregivers (nurses, doctors, therapists, etc.) rather than attendance of the care planning meeting. 1. Do staff include you in decisions about your medicine, therapy, or other treatments? G. Abuse This information must be reported immediately to administration regardless of when it happened (there is no time limit in regards to abuse). 1. Has staff, a resident or anyone else here abused you this includes verbal, physical or sexual abuse? (skip to 2) If Yes, ask who the abuser was, what happened, when it occurred, where it happened, and how often. a. Did you tell staff? If Yes, ask who the resident told. Report immediately to the administrator. 2. Have you seen any resident here being abused? If Yes, ask who the abuser was, what happened, when it occurred, where it happened, and how often. (skip to H) Copyright Providigm, LLC. 2017 Resident Interview - Page 5 of 14

a. Did you tell staff? If Yes, ask who the resident told. Report immediately to the administrator. H. Interaction with Others 1. Have there been any concerns or problems with a roommate or any other resident? (skip to I) a. Has staff addressed the concern(s) to your satisfaction? I. Personal Property 1. Were you encouraged by staff to bring in any personal items? If No: Do you wish to have items brought in? N/A, the resident is a short-stay resident 2. Have you had any missing personal items? If Yes: What is still missing and how long has it been missing. (skip to J) a. Did you tell staff about the missing item(s)? If Yes: Who did you tell about the missing item(s)? (skip to J) b. Has staff told you they are looking for your missing item(s)? If No, do you know who or which department is supposed to be looking for your missing item? J. Pain Emphasize that the end of the question includes with no relief. Ask whether the resident receives interventions for his/her discomfort/pain and whether it relieves the pain. If the medicine does not provide relief, then the answer is Yes. Copyright Providigm, LLC. 2017 Resident Interview - Page 6 of 14

1. Do you have any discomfort now, or have you been having discomfort, such as pain, heaviness, burning, or hurting with no relief? K. ADL Assistance, Urinary Incontinence 1. Do you get the help you need getting dressed, toileting, and cleaning your teeth? If No, ask which if the following areas are a concern. Dressing Toileting Oral care ne of the above (no concerns or doesn t need help). L. Hydration 1. Do you receive the fluids you want between meals? N/A, does not orally take fluids M. Sufficient Staff 1. Do you feel there is enough staff available to make sure you get the care and assistance you need without having to wait a long time? If the answer is No, ask resident for details: When do you have to wait (weekend, evening, morning)? With what task(s) is it that you have to wait to receive assistance? 2. Do you feel safe while receiving care in this facility? (skip to 3) a. Is the care team responsive to your requests and preferences? Copyright Providigm, LLC. 2017 Resident Interview - Page 7 of 14

b. Does the care team explain things in a way that you can understand? c. Do you trust the care team? d. Is your call light answered promptly? 3. Do you feel that the members of the care team work well together? (skip to N) a. Do you feel that the care team has communication problems? Do not know b. Do you feel that the care team has sufficient skill and resources to provide high quality care? Do not know c. Do you feel that all of the members of the care team share your expectations regarding your care and outcomes? Do not know Copyright Providigm, LLC. 2017 Resident Interview - Page 8 of 14

N. Dental 1. Do you have any problems with your teeth, gums, or dentures? (skip to O) a. Are staff taking care of these problems to your satisfaction? N/A, staff unaware and/or resident or family taking care of problem. O. Privacy 1. Does staff provide you privacy when they work with you, changing your clothes, providing treatment? 2. Do you have privacy when on the telephone? N/A, do not use telephone 3. If you would have a visitor, do you have a private place to meet? The facility must make residents aware of locations they can meet privately with their visitors if the resident does not have a private room. P. Exercise of Rights 1. Have you been moved to a different room or had a roommate change in the last nine months? (skip to Q) Copyright Providigm, LLC. 2017 Resident Interview - Page 9 of 14

a. Were you given notice before a room change or a change in roommate? Q. Personal Funds 1. Do you have a personal funds account with the facility? a. Does the facility let you know how much money you have in your account? b. Can you get your money when you need it, including on weekends? (skip to Food Quality) Do not know (skip to Food Quality) Do not know Do not know K. Food Quality If the resident answers No to either of the two following questions, ask for details and specifics about which food(s), meal(s) and dining areas etc. If the resident takes nothing by mouth, code Yes to the following two questions. 2. Does the food taste good and look appetizing? 2. Is the food served at the proper temperature? 3. Are you pleased with your choices related to when you eat? Copyright Providigm, LLC. 2017 Resident Interview - Page 10 of 14

4. Are you pleased with your choices related to where you eat? Satisfaction IMPORTANT : To ensure accurate responses, the following questions require you to show the resident the Visual Scales. 1. Overall, how satisfied are you with this facility? Choose the number that best describes your rating of overall satisfaction. Show Visual Scale - Satisfaction. Dissatisfied Satisfied 1 2 3 4 5 6 7 8 9 10 Resident unable to use Visual Scale 2. Would you recommend this facility to others? Choose the number that best describes how likely you are to recommend this facility. Show Visual Scale - Recommendation. Unlikely Likely 1 2 3 4 5 6 7 8 9 10 Resident unable to use Visual Scale 3. Have any of the staff members been exceptional? If so, who were they and how were they exceptional? Copyright Providigm, LLC. 2017 Resident Interview - Page 11 of 14

4. What can we do to improve your experience here? 5. Is there anything else you would like to share about your life at the facility? Copyright Providigm, LLC. 2017 Resident Interview - Page 12 of 14