2010 National Survey of Residential Care Facilities (NSRCF)

Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_A1_Intro1 This survey is about the characteristics of residential care All facilities
facilities and the individuals who live in them. 1 CONTINUE

Residential care facilities are known by many names, so just

to be clear I would like to read a definition that we are using
to describe a residential care facility that we have provided
on this card.

HAND R SHOWCARD
Residential care facilities are places that are licensed,
registered, listed, certified, or otherwise regulated by the
state and that provide room and board with at least two
meals a day, around-the-clock on-site supervision, and help
with personal care such as bathing and dressing or health
related services such as medication management. These
facilities serve a predominantly adult population. Facilities
licensed to exclusively serve the severely mentally ill or the
developmentally disabled populations are excluded.

F_A1_Intro2 We are interviewing [SAMPLED FACILITY] because it is 1 CONTINUE All facilities

currently licensed as a [LICENSURE CATEGORY], which is
a type of residential care facility.

READ IF MULTI-LEVEL FACILITY

[When you answer the questions, please answer only about
the residential care component of this facility.]

F_A1 This is the first of many questions included in the Pre- 0…995 BEDS All facilities
interview Worksheet that we mailed to your facility. If you
have that form available it would be helpful to reference that
now.

1
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

At this facility, what is the number of licensed, registered, or

certified residential care beds? Include both occupied and
unoccupied beds.

F_A1_CONFIRM Does your facility have less than four beds? 1 YES F_A1 = 0-3
2 NO

F_A1_ABORT I am sorry but your facility is not eligible for this study. Thank 1 CONTINUE F_A1_CONFIRM
you for your time. =1

F_A2 At this facility, what is the number of licensed, registered or All facilities
certified residential care rooms or apartments, where 1-995
residents live?
Exclude rooms within apartments.

F_S14 Is this facility owned by a chain, group, or multi-facility 1 YES All facilities
system? 2 NO

INTERVIEWER, EXPLAIN IF NECESSARY: A chain means

more than one facility under common ownership or
management. This may include facilities within-state or
across multiple states.

F_S15 What is the type of ownership of this facility? 1 Private, for profit All facilities
2 Private Nonprofit
Private, for profit 3 State, county, or local
Private Nonprofit government
State, county, or local government

F_S3a Does this residential care facility only serve adults with 1 YES All facilities
dementia or Alzheimer's disease? 2 NO

2
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_A3 What is the current number of residents living at this 1…995 All facilities
residential care facility?

F_ANEW1 HAND R SHOWCARD 1 ROOM DESIGNED FOR All facilities

ONE PERSON
The next questions are about the residents’ living quarters 2 ROOM DESIGNED FOR
(in the residential care component) at this facility. TWO PERSONS
3 ROOM DESIGNED FOR
Which of these types of living quarters does your facility THREE OR MORE
offer to residents? PERSONS
Any others? 4 STUDIO APARTMENT
5 ONE BEDROOM
SELECT ALL THAT APPLY APARTMENT
6 TWO BEDROOM
APARTMENT
7 THREE BEDROOM
APARTMENT

F_ANEW2Intro I’ll now ask about the rooms (at/in the residential care 1 CONTINUE F_ANEW1 = 1-3
portion of) this facility.

F_ANEW2a How many rooms in this facility are designed for one 1…995 F_ANEW1 = 1
person?

F_ANEW2b How many rooms in this facility are designed for two 1..995 F_ANEW1 = 2
persons?

F_ANEW2c How many rooms in this facility are designed for three or 1…995 F_ANEW1 = 3
more persons?

F_ANEW3a HAND R SHOWCARD 1 MICROWAVE F_ANEW1 = 1-3

2 COOK TOP OR HOT

3
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

(Does this room/do any rooms) contain any of these PLATE

features? Which ones? 3 OVEN
4 REFRIGERATOR
SELECT ALL THAT APPLY
5 KITCHEN SINK
6 NONE OF THE ABOVE
F_ANEW3b Do all or only some of the rooms have a microwave? 1 All F_ANEW3a=1
2 Some and ∑of
F_ANEW2a-2c≠1
F_ANEW3b1 How many? 1-995 F_ANEW3b = 2
F_ANEW3c Do all or only some of the rooms have a cook top or hot 1 All F_ANEW3a=2
plate? 2 Some and ∑of NEW2a-
2c≠1
F_ANEW3c1 How many? 1-995 F_ANEW3c= 2
F_ANEW3d Do all or only some of the rooms have an oven? 1 All F_ANEW3a=3
2 Some and ∑of
F_ANEW2a-2c≠1
F_ANEW3d1 How many? 1-995 F_ANEW3d= 2
F_ANEW3e Do all or only some of the rooms have a refrigerator? 1 All F_ANEW3a=4
2 Some and ∑of
F_ANEW2a-2c≠1
F_ANEW3e1 How many? 1-995 F_ANEW3e= 2
F_ANEW3f Do all or only some of the rooms have a sink in the kitchen 1 All F_ANEW3a=5
area? 2 Some and ∑of
F_ANEW2a-2c≠1
F_ANEW3f1 How many? 1-995 F_ANEW3f= 2
F_A7rev How many rooms have a door to the hallway that can be 1 All F_ANEW1=1-3
locked from the inside- all, some, or none? 2 Some
3 None
F_A7rev1 How many? 1-995 F_ANEWF_A7re
v=2
F_A7_withinrev How many rooms have a bathroom located within the room 1 All F_ANEW1=1-3
or between rooms- 2 Some

4
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

All, some, or none? 3 None

F_A7_withinrev1 How many? 1-995 F_A7withinrev =

2
F_A7arev How many rooms have a full bathroom including a toilet, 1 All F_A7_withinrev =
sink, and shower or tub located within the room or between 2 Some 1-2
rooms… 3 None
All, some, or none?
F_A7arev1 How many? 1-995 F_A7a rev = 2
F_A7brev How many rooms have a half-bath including a sink and toilet 1 All F_A7a = 2-3
located within the room or between rooms… 2 Some
All, some, or none? 3 None
F_A7brev1 How many? 1-995 F_A7b rev = 2

F_ANEW4Intro The next questions are about this facility’s apartments. 1 CONTINUE F_ANEW1 = 4-7

F_ANEW4a How many studio apartments are there? 1…995 F_ANEW1 = 4

F_ANEW4b How many one bedroom apartments are there? 1…995 F_ANEW1 = 5

F_ANEW4c How many two bedroom apartments are there? 1…995 F_ANEW1 = 6

F_ANEW4d How many three bedroom apartments are there? 1…995 F_ANEW1 = 7

F_ANEW5a HAND R SHOWCARD 1 MICROWAVE F_ANEW1 = 4-7

2 COOK TOP OR HOT
(Does this apartment/do any apartments) contain any of PLATE
these features? Which ones?
3 OVEN
SELECT ALL THAT APPLY 4 REFRIGERATOR
5 KITCHEN SINK
6 NONE OF THE ABOVE

5
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_ANEW5b Do all or only some of the apartments have a microwave? 1 All F_ANEW5a=1
2 Some and ∑of
NOTE: APARTMENT IS CONSIDERED TO HAVE A F_ANEW4a-4d≠1
MICROWAVE EVEN IN MICROWAVE CANNOT BE
PLUGGED IN/HAS BEEN DISABLED FOR THE
RESIDENT’S SAFETY.
F_ANEW5b1 How many? 1-995 F_ANEW5b = 2
F_ANEW5c Do all or only some of the apartments have a cooktop or hot 1 All F_ANEW5a=2
plate? 2 Some and ∑of
F_ANEW4a-4d≠1
F_ANEW5c1 How many? 1-995 F_ANEW5c = 2
F_ANEW5d Do all or only some of the apartments have an oven? 1 All F_ANEW5a=3
2 Some and ∑of
F_ANEW4a-4d≠1
F_ANEW5d1 How many? 1-995 F_ANEW5d = 2
F_ANEW5e Do all or only some of the apartments have a refrigerator? 1 All F_ANEW5a=4
2 Some and ∑of
F_ANEW4a-4d≠1
F_ANEW5e1 How many? 1-995 F_ANEW5e = 2
F_ANEW5f Do all or only some of the apartments have a sink in the 1 All F_ANEW5a=5
kitchen area? 2 Some and ∑of
F_ANEW4a-4d≠1
F_ANEW5f1 How many? 1-995 F_ANEW5f = 2
F_A7rev_apt How many apartments have a door to the hallway that can 1 All F_ANEW1=4-7
be locked from the inside, 2 Some
All, some, or none? 3 None
F_A7rev1_apt How many? 1-995 F_A7rev_apt = 2

F_A7_withinrev_a How many apartments have a bathroom located within the 1 All F_ANEW1=4-7
pt apartment or between apartments, 2 Some
3 None
All, some, or none?

6
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_A7_withinrev1_ How many? 1-995 F_A7_withinrev_

apt apt = 2

F_A7arev_apt How many apartments have a full bathroom including a 1 All F_A7_withinrev_
toilet, sink, and shower or tub located within the apartment 2 Some apt = 1-2
or between apartments… 3 None

All, some or none?

F_A7arev1_apt How many? 1-995 F_A7arev_apt= 2

F_A7b_apt How many apartments have a half-bath including a sink and 1 All F_A7_withinrev_
toilet located within the apartment or between apartments… 2 Some apt= 1-2
3 None
All, some, or none?

F_A7b1_apt How many? 1-995 F_A7b_apt

=2
F_A8 Does the facility have a common kitchen area that any 1 YES All facilities
resident can use? 2 NO

F_A9 How many of the [NUMBER] residents live with a spouse or 0…995 All facilities
other relative? For example, if there is one couple who lives
together, you would report that two residents live with a
spouse or relative.

F_A10 READ RESPONSES IF NECESSARY. 1 LESS THAN 5 YEARS All facilities

2 5 TO 9 YEARS
What is the total number of years this facility has been (in 3 10 TO 19 YEARS
operation/operating as a residential care facility)? 4 20 OR MORE YEARS

7
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_A11 Was [SAMPLED FACILITY] purposely built as a residential 1 YES All facilities
care facility? 2 NO

F_A12a (In the residential care portion of this facility,) how many 1 All All facilities
resident (rooms/apartments) have… 2 Some
smoke detectors? 3 None

Would you say…?

All
Some
None

F_A12b (In the residential care portion of this facility,) how many 1 All All facilities
common areas have… 2 Some
smoke detectors? 3 None

Would you say…?

All
Some
None

F_A12c (In the residential care portion of this facility,) how many 1 All All facilities
resident (rooms/apartments) have… 2 Some
a sprinkler system? 3 None

Would you say…?

All
Some
None

F_A12d (In the residential care portion of this facility,) how many 1 All All facilities
common areas have… 2 Some

8
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

a sprinkler system? 3 None

Would you say…?

All
Some
None

F_A12e (In the residential care portion of this facility,) how many 1 All All facilities
hallways have supported or grab rails on one or both sides? 2 Some
3 None
Would you say…?
All
Some
None

F_A12f (In the residential care portion of this facility,) how many 1 All All facilities
common areas have widened hallways or doorways that can 2 Some
accommodate wheelchairs? 3 None

Would you say…?

All
Some
None

F_A12g (In the residential care portion of this facility,) how many 1 All All facilities
(rooms/apartments) have an emergency call or personal 2 Some
response system? This may include emergency devices 3 None
worn by residents.

Would you say…?

All
Some
None

9
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_A12h (In the residential care portion of this facility,) how many 1 All All facilities
(rooms/apartments) are… 2 Some
wheelchair accessible? 3 None

Would you say…?

All
Some
None

F_A12i (In the residential care portion of this facility,) how many 1 All All facilities
bathrooms have enough space for a wheelchair to enter, 2 Some
about 3 ft, and turn around, about 5ft x 5ft? 3 None

Would you say…?

All
Some
None

F_A12j (In the residential care portion of this facility,) how many 1 All All facilities
bathrooms have grab bars in the shower or tub area? 2 Some
3 None
Would you say…?
All
Some
None

F_A15 During the past 90 days, did this residential care facility 1 YES All facilities
provide any short-term respite care? 2 NO

F_A16 Does this facility provide adult day health or adult day care 1 YES All facilities
services to non-residents? 2 NO

10
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_A17 Does this facility currently serve any persons with 1 YES All facilities
developmental disabilities such as mental retardation, 2 NO
autism, or Down syndrome?

F_A18 Does this facility currently serve any persons with severe 1 YES All facilities
mental illness such as schizophrenia and psychosis? Please 2 NO
do not include Alzheimer's disease or other dementias.

F_A18a HAND R SHOWCARD 1 YES All facilities

2 NO
Please look at this card. We would now like to ask you
about how the facility manages risky behavior by residents.
By risky behavior, we mean when residents do things that
staff think pose a risk to their health and safety - such
as refusing to take prescribed medications, not using a
walker when their balance is poor, or not complying with
prescribed diets.

Some facilities use a formal written document called a

managed risk agreement or a formal negotiated risk
agreement, which documents the risky behavior,
discussions with the resident about the behavior,
alternatives to the behavior presented by staff, and
agreements reached between the facility and the resident
about the behavior. Some facilities also use these
documents as liability waivers for harm resulting from risky
behavior. This document is different from a Plan of Care or a
Resident Agreement.

Does this facility develop a formal negotiated risk agreement

with any of the residents?

11
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_A18b Instead of a formal negotiated risk agreement, does this 1 YES F_A18a = 2
facility address risky behaviors in some other formal written 2 NO
document?

F_A19_Intro The next questions ask about items residents are allowed to 1 CONTINUE All facilities
bring when they move into this facility.

F_A19 1 Large furniture such as a All facilities

What types of personal items or furniture may residents couch, bed, or dining room
bring? table.
2 Small furniture such as a
Large furniture such as a couch, bed, or dining room table. desk, bookcase, chair, lamp,
Small furniture such as a desk, bookcase, chair, lamp, or or small table.
small table. 3 Personal items such as
Personal items such as pictures, bed linens, or wall pictures, bed linens, or wall
decorations. decorations.
4 NONE OF THE ABOVE
CODE ALL THAT APPLY
F_A20 Does the facility provide a common pet such as a cat, dog, 1 YES All facilities
or bird? 2 NO

F_A20a Are residents ever allowed to have a personal pet such as a 1 YES All facilities
cat, dog, or bird that lives at the facility? 2 NO

F_A21 Is there space at this facility for residents to park their car? 1 YES All facilities
2 NO
F_A22_Intro The next questions ask about resident source of payment. 1 CONTINUE All facilities

F_A22 Is this residential care facility certified or registered to 1 YES All facilities
participate in Medicaid? 2 NO

12
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_A23 During the last 30 days, how many of the residents had 0…995 F_A22 = 1
some or all of their long-term care services paid by
Medicaid?

F_A24 Does this facility currently have anyone who is on a waiting 1 YES All facilities
list to be admitted to this facility as soon as a place becomes 2 NO
available?

F_A25 What is the current number of people waiting to be admitted 1…500 F_A24 = 1
to this facility as soon as a place becomes available?

F_A26 What is the average length of time that prospective MONTHS F_A24 = 1
residents are waiting to be admitted to this facility? Please DAYS
respond in months and/or days.

F_A27_Intro The next questions ask about resident admission and 1 CONTINUE All facilities
discharge.

F_A27 How many residents moved into this facility over the past 12 0…500 All facilities
months? Please count each couple as 2 residents. Also, do
not include someone returning from a hospital stay if this
facility held the bed for the resident. Residents should be
counted only once.

F_A32 In the last 12 months, how many residents died? 0…500 All facilities

F_A30 Over the last 12 months, how many residents moved out of 0…500 All facilities
this facility? Exclude someone who has moved out if the
facility is currently holding a bed for the resident.
Exclude deaths.

F_A31_hosp Where did the residents go after they moved out? 0…500 F_A30 = 1-500

13
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

Hospital

F_A31_nursing (Where did the residents go after they moved out?) 0…500 F_A30 = 1-500

Nursing home
F_A31_otherrcf (Where did the residents go after they moved out? 0…500 F_A30 = 1-500

Other residential care facility

F_A31_residence (Where did the residents go after they moved out? 0…500 F_A30 = 1-500

Private residence
F_A31_other (Where did the residents go after they moved out? 0…500 F_A30 = 1-500

Some other place

F_A30a Over the last 12 months, of those residents who moved 0…500 F_A30 = 1-500
elsewhere, how many left because the cost of care,
including housing, meals, and services required to meet
their needs, exceeded their ability to pay?

F_A33_Intro The next questions are about facility staff. First, we will ask 1 CONTINUE All facilities
how many total hours were worked in the last 7 days (or the
last work week) by paid staff (for the residential care
component of this facility).

In your calculations of staff hours, please include all staff

that provide direct care to residents, including full-time and
part-time staff employees, and contract, temporary, and
agency workers.

Direct care refers to time spent meeting the needs of

individual residents, such as helping them walk to dinner,
helping them dress, or providing them with assistance with

14
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

medications.

F_A33a During the last 7 days or last work week, how many total All facilities
hours were worked by the following paid staff (for the 0..999
residential care component this facility).

Registered Nurses or RNs

F_A33b (During the last 7 days or last work week, how many total All facilities
hours were worked by the following paid staff (for the 0..999
residential care component of this facility).)

Licensed Practical Nurses, also called an L.P.N. or Licensed

Vocational Nurses also called an LVN.

F_A33c (During the last 7 days or last work week, how many total All facilities
hours were worked by the following paid staff (for the 0..1999
residential care component of this facility)

Personal care aides, including certified nursing assistants, .

(CNAs) and medication technicians.

F_A33d (During the last 7 days or last work week, how many total All facilities
hours were worked by the following paid staff (for the 0..999
residential care component of this facility).)

Activities director or activities staff

F_A33e (During the last 7 days or last work week, how many total All facilities
hours were worked by the following paid staff (for the 0..999
residential care component of this facility).)

15
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

Administrators, directors, assistant administrators or

assistant directors - direct care time only

(Direct care time by administrators or directors refers to time

spent meeting the needs of individual residents, such as
helping them walk to dinner, helping them dress, or
providing them with medications. It does not include the time
spent on the overall management of the facility.)

F_A34 Does this facility use contract workers to provide direct care 1 YES All facilities
to residents? 2 NO

F_A35 During the past 7 days or last work week, did your facility 1 YES All facilities
use any volunteers to help your residents or this facility's 2 NO
staff in any way?

F_A36 During the last 7 days or last work week, about how many F_A35 = 1
0..995
volunteer workers provided services at the facility at least
once?

F_A36a What kinds of services do they provide? 1 General office help F_A35 = 1
2 Homemaker/Household
CODE ALL THT APPLY services
General office help 3 Personal care (haircuts,
Homemaker/Household services nail care, massage, etc.)
Personal care (haircuts, nail care, massage, etc.) 4 Transportation services
Transportation services 5 Visiting with patients
Visiting with patients 6 Bereavement/family
Bereavement/family support support
Religious/spiritual activities 7 Religious/spiritual
Assist residents at Mealtime activities
Shopping 8 Assist residents at

16
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

Social and recreational activities Mealtime

9 Shopping
10 Social and recreational
activities
11 Exercise
12. Other services

F_A36b During the last 7 days or last work week, how many of your 0..500 F_A35 = 1
facility's residents received services from any of your
volunteer workers?

F_A37 During a typical night how many staff are on-duty and 0..500 All facilities
awake? Please do not count security guards.

F_A38a These next questions ask how many full-time and part-time All facilities
persons are currently employed by this facility (for 0..99
residential care). Please count full-time and part-time
employees. Do not include contract, temporary, and agency
workers. Please count each employee only once based
upon their primary responsibilities.

As of today, how many of the following full-time and part-

time persons are currently employed by this facility (for
residential care).

Administrators, Directors, assistant Administrators and

assistant Directors?

F_A38b (As of today, how many of the following full time and part All facilities
time staff are currently employed at this facility) (for 0..99
residential care).

Registered Nurses or RNs

17
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_A38c (As of today, how many of the following full-time and part- All facilities
time staff are currently employed by this facility) (for 0..99
residential care).

Licensed Practical Nurses also called LPNs or Licensed

Vocational Nurses also called LVNs

F_A38d (As of today, how many of the following full-time and part- All facilities
time staff are currently employed by this facility) (for 0..995
residential care).

Personal Care Aides, including Certified Nursing Assistants

and medication technicians

F_A39a During the past 12 months, how many of the following full- All facilities
time and part-time employees have resigned or been 0..99
terminated (from residential care).

Administrators, Directors, Assistant Administrators and

Assistant Directors

F_A39b (During the past 12 months, how many of the following full- All facilities
time and part-time employees have resigned or been 0..99
terminated (from residential care).

Registered Nurses or RNs

F_A39c (During the past 12 months, how many of the following full- All facilities
time and part-time employees have resigned or been 0..99
terminated (from residential care).

18
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

Licensed Practical Nurses also called LPNs or Licensed

Vocational Nurses also called LVNs

F_A39d (During the past 12 months, how many of the following full- All facilities
time and part-time employees have resigned or been 0..99
terminated (from residential care).

Personal Care Aides and nursing assistants, including CNAs

and medication technicians

F_A40a HAND R SHOWCARD 1 0% All facilities

2 1 to 20%
About what percentage of this facility’s employees received 3 21-40 %
a flu shot last flu season? 4 41-50%
5 51-60%
6 61-80%
7 81-99%
8 100%

F_A40b HAND R SHOWCARD 1 VACCINATIONS All

Does this facility do any of the following to encourage RECOMMENDED facilities
employees’ influenza vaccinations? 2 VACCINATIONS
Anything else? OFFERED ON SITE
3 VACCINATIONS
SELECT ALL THAT APPLY. OFFERED FOR FREE
4 VACCINATIONS
OFFERED AT REDUCED
COST
5 STAFF INCENTIVES
PROVIDED FOR
VACCINATION
6 PROOF OF

19
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

VACCINATION (OR
CONTRAINDICATION)
REQUIRED AS A
CONDITION OF WORK/
EMPLOYMENT
7 FURLOUGH OR PATIENT
RESTRICTION POLICY
FOR EMPLOYEES
DEVELOPING INFLUENZA-
LIKE ILLNESS
8 NONE OF THE ABOVE

F_A40c HAND R SHOWCARD 1 FACILITY-WIDE All facilities

STANDING ORDERS
Which vaccination program best describes what is being 2 PRE-PRINTED
used in your facility for influenza? ADMISSION ORDERS
3 ADVANCE PHYSICIAN/
1
HELP SCREEN NURSE PRACTITIONER
ORDERS FOR ALL OF
THEIR RESIDENTS

1
Immunization Program Definitions

1. Facility wide standing orders: An institutional policy authorizes appropriate nursing or other non-physician staff to immunize residents by institution- or medical director-approved
protocol without the need for a written or verbal order from the resident’s personal physician before administering the vaccine.

2. Pre-printed admission orders: Each resident’s personal physician signs the facility’s preprinted admission order before administering the vaccine to the resident. The preprinted
order may address the resident’s current vaccination needs as well as those in the future.

3. Advance physician/nurse practitioner orders for all of their patients: Issued by an attending physician and authorizes immunization of ALL of the physician’s patients who are
residents of the facility.

4. Personal physician order for each resident: Each resident’s personal physician is responsible for signing an individual order for every vaccine before it is administered to the
resident.

20
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

4 PERSONAL PHYSICIAN
ORDER FOR EACH
RESIDENT
5 NONE OF THE ABOVE

F_A40d Which type of vaccination program best describes what is 1 FACILITY-WIDE All faciliteis
being used in your facility for pneumonia? Please select STANDING ORDERS
one. 2 PRE-PRINTED
ADMISSION ORDERS
2
HELP SCREEN . 3 ADVANCE PHYSICIAN/
NURSE PRACTITIONER
ORDERS FOR ALL OF
THEIR RESIDENTS
4 PERSONAL PHYSICIAN
ORDER FOR EACH
RESIDENT
5 NONE OF THE ABOVE

F_A40e Has this facility developed a written plan for management of 1 NO, NOT STARTED All facilities
residents during an influenza pandemic? 2 YES, IN PROGRESS
3 YES, COMPLETED
F_A40 Does this facility provide on-going, in-service training to 1 YES F_A38 ≠ 0
personal care aides? 2 NO

F_A41 Prior to providing care to residents, how many hours of 1 No formal training F_A38 ≠ 0
formal training are required of personal care aides? 2 Less than 75 hours of
training
READ CHOICES 3 75 hours of training
No formal training 4 More than 75 hours of
Less than 75 hours of training training

2
SEE Footnote 1.

21
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

75 hours of training
More than 75 hours of training

F_A43 In addition to helping with activities of daily living, such as 1 Housekeeping F_A38 ≠ 0
dressing and assistance with medications, do personal care 2 Janitorial services
aides routinely perform any of the following tasks... 3 Assistance with food
preparation
Housekeeping 4 Assistance with
Janitorial services recreational activities
Assistance with food preparation 5 Resident’s personal
Assistance with recreational activities laundry
Resident’s personal laundry 6 Transportation or escort
Assistance with medications services for residents
Transportation or escort services for residents 7 NONE OF THE ABOVE

F_A44a Does this facility offer the following to personal care 1 YES F_A38 ≠ 0
aides…? 2 NO

health insurance that includes family coverage

F_A44b (Does this facility offer the following to personal care aides?) 1 YES F_A38 ≠ 0 AND
2 NO F_A44a = 2
health insurance for the employee only

F_A44c (Does this facility offer the following to personal care 1 YES F_A38 ≠ 0
aides…?) 2 NO

life insurance

F_A44e (Does this facility offer the following to personal care 1 YES F_A38 ≠ 0
aides…?) 2 NO

22
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

a pension, a 401(k), or a 403(b)

F_A44f (Does this facility offer the following to personal care 1 YES F_A38 ≠ 0
aides…?) 2 NO

personal time off, vacation time, or sick leave

F_A45 Does this facility pay for more than half of the personal care 1 YES F_A38 ≠ 0 AND
aide’s health insurance premium? 2 NO (F_A44a or
F_A44b = 1)
F_A46_Intro The next questions ask about the types of information 1 CONTINUE All facilities
maintained by this facility.

F_A46 Before or upon admission, does this facility conduct a formal 1 YES All facilities
functional assessment of residents using a standardized 2 NO
tool? Functional means physical activities of daily living,
such as eating, bathing, and dressing, or cognitive
functioning.

F_A47 Does this assessment include a physical assessment, 1 PHYSICAL F_A46 = 1

cognitive assessment, or both? ASSESSMENT
2 COGNITIVE
ASSESSMENT
3 BOTH PHYSICAL AND
COGNITIVE ASSESSMENT

F_A48 An individual service plan details the personalized services 1 YES All facilities
needed by the resident and what will be provided to him or 2 NO
her by the facility. The service plan is usually updated
regularly or as the residents’ care needs change.

Does this facility develop formal individual service plans?

23
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_A49 Other than for accounting or billing purposes, does this 1 YES All facilities
facility use Electronic Health Records? 2 NO

This is a computerized version of the resident’s health and

personal information used in the management of the
resident’s health care.

F_A49b Other than for accounting or billing purposes, does this 1 YES F_A49A=2
facility have a computerized system for its Resident Service 2 NO
Records to keep track of the services provided to each
resident?

IF NEEDED:
Resident service records are the facility’s record of the
services being provided to each resident.

F_A50 HAND R SHOWCARD 1 RESIDENT All facilities

DEMOGRAPHICS
Which of the following computerized capabilities does this 2 MEDICAL PROVIDER
facility have? INFORMATION
3 FUNCTIONAL
SELECT ALL THAT APPLY ASSESSMENTS
4 INDIVIDUAL SERVICE
PLANS
5 CLINICAL NOTES, SUCH
AS MEDICAL HISTORY
AND DAILY PROGRESS
NOTES
6 PATIENT PROBLEMS
LIST
7 MEDICATION
ADMINISTRATION

24
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

8 MAINTAINING LISTS OF
RESIDENT’S
MEDICATIONS
9 MAINTAINING ACTIVE
MEDICATION ALLERGY
LIST
10 ORDERS FOR
PRESCRIPTIONS
11 WARNING OF DRUG
INTERACTIONS OR
CONTRAINDICATIONS
12 ORDERS FOR TESTS
13 VIEWING
LABORATORY/ IMAGING
RESULTS
14 REMINDERS FOR
GUIDELINE BASED
INTERVENTIONS OR
SCREENING TESTS
15 DISCHARGE AND
TRANSFER SUMMARIES
16 PUBLIC HEALTH
REPORTING
17 NONE OF THE ABOVE
F_A51 HAND R SHOWCARD 1 PHYSICIAN F_A50 ≠ 17
2 NURSING HOME
Does this facility’s computerized system support electronic 3 HOSPITAL
health information exchange with any of the following- for 4 PHARMACY
example, sending electronic records from this facility to a 5 LABORATORY/TESTS
hospital? 6 OTHER HEALTH OR
LONG-TERM CARE
SELECT ALL THAT APPLY PROVIDER
7 RESIDENT’S PERSONAL

25
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

HEALTH RECORD
8 PUBLIC HEALTH
REPORTING
9 CORPORATE OFFICE
10 ELECTRONIC
INFORMATION IS NOT
EXCHANGED

F_A51a Does this facility’s staff use any system for Electronic Point 1 YES All facilities
of Care Documentation? This includes PDA’s (Personal 2 NO
Digital Assistants), Notebook PCs, or other portable hand
held devices.

F_A52a_Intro The next questions involve resident demographics. 1 CONTINUE All facilities

F_A53 As of midnight last night, how many residents are of All facilities
Hispanic, Latino, or Spanish origin or descent? 0..999

F_A52_male As of midnight last night, what is the total number of male All facilities
residents living at this facility? 0..995

F_A52_female As of midnight last night, what is the total number of female 0..995 All facilities
residents living at this facility?

F_A52a_1 As of midnight last night, how many residents are in the All facilities
following age categories? 0..999

17 and under

F_A52a_2 (As of midnight last night, how many residents are in the All facilities
following age categories?) 0..999

26
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

18-54

F_A52a_3 (As of midnight last night, how many residents are in the All facilities
following age categories?) 0..999

55-64

F_A52a_4 (As of midnight last night, how many residents are in the All facilities
following age categories?) 0..999

65-74

F_A52a_5 (As of midnight last night, how many residents are in the All facilities
following age categories?) 0..999

75-84

F_A52a_6 (As of midnight last night, how many residents are in the All facilities
following age categories?) 0..999

Age 85 and over

F_A54_1 As of midnight last night, how many residents are...? All facilities
0..999
White or Caucasian

F_A54_2 (As of midnight last night, how many residents are...?) All facilities
0..999
Black or African American

F_A54_3 (As of midnight last night, how many residents are...?) All facilities
0..999
Asian

27
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_A54_4 (As of midnight last night, how many residents are...?) All facilities
0..999
Native Hawaiian or other Pacific Islander

F_A54_5 (As of midnight last night, how many residents are...?) All facilities
0..999
American Indian or Alaska Native

F_A55_Intro The next questions ask about the cognitive, functional, and 1 CONTINUE All facilities
health status of residents (in the residential care component
of this facility)
.
F_A55 During the last 7 days, how many of this facility's current 0..500 All facilities
residents had short-term memory problems or seemed
disoriented all or most of the time?

This includes, for example, residents who are not able to

remember things after a short while and residents who have
difficulty remembering where their room is, or difficulty
recognizing staff names or faces.

F_A56a HAND R SHOWCARD 1 100% All facilities

2 75 - 99%
What percentage of the residents… 3 50 - 74%
4 25 - 49%
have had an episode of urinary incontinence during the last 5 11-24%
7 days? 6 1-10%
7 0%

28
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_A56b (What percentage of the residents…) 1 100% All facilities

2 75 - 99%
are confined to a bed or chair because of health problems? 3 50 - 74%
4 25 - 49%
5 11-24%
6 1-10%
7 0%

F_A56c (What percentage of the residents…) 1 100% All facilities

2 75 - 99%
use a wheelchair or electric scooter to get around in the 3 50 - 74%
facility? 4 25 - 49%
5 11-24%
6 1-10%
7 0%

F_A56d (What percentage of the residents…) 1 100% All facilities

2 75 - 99%
currently receive assistance in transferring in and out of bed 3 50 - 74%
or a chair? 4 25 - 49%
5 11-24%
6 1-10%
7 0%

F_A56e (What percentage of the residents…) 1 100% All facilities

2 75 - 99%
currently receive assistance in eating, like cutting up food? 3 50 - 74%
4 25 - 49%
5 11-24%
6 1-10%
7 0%

29
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_A57a (For what percentage of the residents do you…) 1 100% All facilities
2 75 - 99%
manage, supervise or store medications or provide 3 50 - 74%
assistance with self-administration of medications? 4 25 - 49%
5 11-24%
6 1-10%
7 0%

F_A57b (For what percentage of the residents do you…) 1 100% All facilities
2 75 - 99%
provide or arrange assistance with locomotion, that is, 3 50 - 74%
helping the resident walk or wheel him/herself around the 4 25 - 49%
facility? 5 11-24%
6 1-10%
7 0%

F_A57c (For what percentage of the residents do you…) 1 100% All facilities
2 75 - 99%
provide or arrange assistance using the bathroom? This 3 50 - 74%
includes reminders to use the toilet, scheduled toileting, 4 25 - 49%
getting on or off the toilet, cleaning him/herself, arranging 5 11-24%
clothing, and changing adult incontinence supplies. 6 1-10%
7 0%

F_A58 Does this residential care facility have a distinct unit, wing, 1 YES F_S3a ≠ 1
or floor that is designated as a Dementia or Alzheimer's 2 NO
Special Care Unit?

F_A59_Intro The next set of questions is about the Dementia or 1CONTINUE F_A58 = 1
Alzheimer's unit, floor, or wing. When answering these
questions, please answer only for that unit.

30
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_A59a In the Dementia or Alzheimer's Special Care unit, please tell 0..500 F_A58 = 1
me the number of licensed beds.

F_A60 What is the current number of residents living in the 0..500 F_A58 = 1
Dementia/Alzheimer's unit?

F_A61 HAND R SHOWCARD 1 LOCKED EXIT DOORS F_A58 = 1 or

2 DOORS WITH ALARMS F_S3a = 1
Which of the following features does this (facility/Dementia 3 DOORS WITH KEY
or Alzheimer's Special Care Unit) have? PADS/ELECTRONIC KEYS
4 CLOSED CIRCUIT TV
MONITORING
5 PERSONAL
MONITORING DEVICES
6 AN ENCLOSED
COURTYARD
7 HIGHER STAFF-TO-
RESIDENT RATIOS
COMPARED TO OTHER
UNITS
8 SPECIALLY TRAINED
STAFF
9 DEMENTIA-SPECIFIC
ACTIVITIES AND
PROGRAMMING

F_BIntro The next questions will be about policies and services 1 CONTINUE All facilities
provided (at FACILITY NAME/ by the residential care
component of this facility).

F_B1a In terms of this facility's admission policy, do you admit a 1 YES All facilities
resident who...? 2 NO

31
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

3 NO SPECIFIC POLICY
Is unable to leave the facility in an emergency without help -WE MAKE DECISIONS
ON A CASE BY CASE
BASIS

F_B3a In terms of this facility's discharge policy, do you discharge a 1 YES F_B1a = 2 or 3
resident who...? 2 NO
3 NO SPECIFIC POLICY --
Is unable to leave the facility in an emergency without help WE MAKE DECISIONS ON
A CASE BY CASE BASIS
F_B1b In terms of this facility's admission policy, do you admit a 1 YES All facilities
resident who..?. 2 NO
3 NO SPECIFIC POLICY --
Has moderate to severe cognitive impairment, that is, the WE MAKE DECISIONS ON
resident does not know who they are A CASE BY CASE BASIS

F_B3b In terms of this facility's discharge policy, do you discharge a 1 YES F_B1b = 2 or 3
resident who...? 2 NO
3 NO SPECIFIC POLICY --
Has moderate to severe cognitive impairment, that is, the WE MAKE DECISIONS ON
resident does not know who they are A CASE BY CASE BASIS

F_B1c In terms of this facility's admission policy, do you admit a 1 YES All facilities
resident who...? 2 NO
3 NO SPECIFIC POLICY --
Exhibits problem behavior such as wandering, temper WE MAKE DECISIONS ON
outbursts, or combative behavior to other residents A CASE BY CASE BASIS

F_B3c In terms of this facility's discharge policy, do you discharge a 1 YES F_B1c = 2 or 3
resident who...? 2 NO
3 NO SPECIFIC POLICY --
Exhibits problem behavior such as wandering, temper WE MAKE DECISIONS ON

32
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

outbursts, or combative behavior to other residents A CASE BY CASE BASIS

F_B1d In terms of this facility's admission policy, do you admit a 1 YES All facilities
resident who...? 2 NO
3 NO SPECIFIC POLICY --
Needs skilled nursing care on a regular basis WE MAKE DECISIONS ON
A CASE BY CASE BASIS
F_B3d In terms of this facility's discharge policy, do you discharge a 1 YES F_B1d = 2 or 3
resident who...? 2 NO
3 NO SPECIFIC POLICY --
Needs skilled nursing care on a regular basis WE MAKE DECISIONS ON
A CASE BY CASE BASIS
F_B1e In terms of this facility's admission policy, do you admit a 1 YES All facilities
resident who...? 2 NO
3 NO SPECIFIC POLICY --
Needs daily monitoring for a health condition like assistance WE MAKE DECISIONS ON
taking insulin or monitoring blood sugar A CASE BY CASE BASIS

F_B3e In terms of this facility's discharge policy, do you discharge a 1 YES F _B1e = 2 or 3
resident who...? 2 NO
3 NO SPECIFIC POLICY --
Needs daily monitoring for a health condition like assistance WE MAKE DECISIONS ON
taking insulin or monitoring blood sugar A CASE BY CASE BASIS

F_B1f In terms of this facility's admission policy, do you admit a 1 YES All facilities
resident who...? 2 NO
3 NO SPECIFIC POLICY --
Is regularly incontinent of urine WE MAKE DECISIONS ON
A CASE BY CASE BASIS
F_B3f In terms of this facility's discharge policy, do you discharge a 1 YES F B1f = 2 or 3
resident who...? 2 NO
3 NO SPECIFIC POLICY --

33
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

Is regularly incontinent of urine WE MAKE DECISIONS ON

A CASE BY CASE BASIS
F_B1g In terms of this facility's admission policy, do you admit a 1 YES All facilities
resident who...? 2 NO
3 NO SPECIFIC POLICY --
Is regularly incontinent of feces WE MAKE DECISIONS ON
A CASE BY CASE BASIS
F_B3g In terms of this facility's discharge policy, do you discharge a 1 YES F_B1g = 2 or 3
resident who...? 2 NO
3 NO SPECIFIC POLICY --
Is regularly incontinent of feces WE MAKE DECISIONS ON
A CASE BY CASE BASIS
F_B1h In terms of this facility's admission policy, do you admit a 1 YES All facilities
resident who...? 2 NO
3 NO SPECIFIC POLICY --
Is regularly incontinent of urine and feces WE MAKE DECISIONS ON
A CASE BY CASE BASIS
F_B3h In terms of this facility's discharge policy, do you discharge a 1 YES F_B1h = 2 or 3
resident who...? 2 NO
3 NO SPECIFIC POLICY --
Is regularly incontinent of urine and feces WE MAKE DECISIONS ON
A CASE BY CASE BASIS
F_B1i In terms of this facility's admission policy, do you admit a 1 YES All facilities
resident who...? 2 NO
3 NO SPECIFIC POLICY --
Needs two people to help them get in and out of bed or WE MAKE DECISIONS ON
needs a Hoyer lift to get in and out of bed A CASE BY CASE BASIS

F_B3i In terms of this facility's discharge policy, do you discharge a 1 YES F_B1i = 2 or 3
resident who...? 2 NO
3 NO SPECIFIC POLICY --
Needs two people to help them get in and out of bed or WE MAKE DECISIONS ON

34
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

needs a Hoyer lift to get in and out of bed A CASE BY CASE BASIS

F_B1j In terms of this facility's admission policy, do you admit a 1 YES All facilities
resident who...? 2 NO
3 NO SPECIFIC POLICY --
Has a history of drug or alcohol abuse WE MAKE DECISIONS ON
A CASE BY CASE BASIS
F_B3j In terms of this facility's discharge policy, do you discharge a 1 YES F_B1j = 2 or 3
resident who...? 2 NO
3 NO SPECIFIC POLICY --
Abuses drugs or alcohol WE MAKE DECISIONS ON
A CASE BY CASE BASIS
F_B1k In terms of this facility's admission policy, do you admit a 1 YES All facilities
resident who...? 2 NO
3 NO SPECIFIC POLICY --
Requires end of life care? WE MAKE DECISIONS ON
A CASE BY CASE BASIS
F_B3k_ In terms of this facility's discharge policy, do you discharge a 1 YES F_B1k = 2 or 3
resident who...? 2 NO
3 NO SPECIFIC POLICY --
Requires end of life care? WE MAKE DECISIONS ON
A CASE BY CASE BASIS
F_B2 Are there any (other) reasons for which you would refuse to 1 YES All facilities
admit someone? 2 NO

F_B2sp What are these other reasons you would refuse to admit SPECIFY F_B2 = 1
someone?

F_B4 Are there any (other) reasons for which you would discharge 1 YES All facilities
someone? 2 NO

35
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_B4sp What are those (other) reasons you would discharge SPECIFY F_B4 = 1
someone?
F_B5Intro Does this facility provide any of the following services to 1 CONTINUE All facilities
residents...?

F_B5a (Does this facility provide any of the following services to 1 YES All facilities
residents...?) 2 NO

Special diets

F_B5a1_1 Is this service provided by paid facility employees, other 1 FACILITY EMPLOYEES F_B5a = 1
types of workers, or both? 2 OTHER TYPES OF
WORKERS
3 BOTH

F_B5b Does this facility provide... 1 YES All facilities

2 NO
Assistance with activities of daily living

F_B5b1_1 Is this service provided by paid facility employees, other 1 FACILITY EMPLOYEES F_B5b = 1
types of workers, or both? 2 OTHER TYPES OF
WORKERS
3 BOTH

F_B5c Does this facility provide... 1 YES All facilities

2 NO
Assistance with a bath or shower at least once a week

F_B5c1_1 Is this service provided by paid facility employees, other 1 FACILITY EMPLOYEES F_B5c = 1
types of workers, or both? 2 OTHER TYPES OF
WORKERS
3 BOTH

36
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_B5d Skilled nursing services are services that must be performed 1 YES All facilities
by a registered nurse (RN), or a licensed practical nurse 2 NO
(LPN) and are medical in nature.

Does this facility provide...

Skilled nursing services

F_B5d1_1 Is this service provided by paid facility employees, other 1 FACILITY EMPLOYEES F_B5d = 1
types of workers, or both? 2 OTHER TYPES OF
WORKERS
3 BOTH

F_B5e Does this facility provide... 1 YES All facilities

2 NO
Basic health monitoring, such as blood pressure and weight
checks.

F_B5e1_1 Is this service provided by paid facility employees, other 1 FACILITY EMPLOYEES F_B5e = 1
types of workers, or both? 2 OTHER TYPES OF
WORKERS
3 BOTH

F_B5f Does this facility provide... 1 YES All facilities

2 NO
Social and recreational activities within the facility

F_B5f1_1 Is this service provided by paid facility employees, other 1 FACILITY EMPLOYEES F_B5f = 1
types of workers, or both? 2 OTHER TYPES OF
WORKERS
3 BOTH

37
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_B5g Does this facility provide... 1 YES All facilities

2 NO
Social and recreational activities outside the facility

F_B5g1_1 Is this service provided by paid facility employees, other 1 FACILITY EMPLOYEES F_B5g = 1
types of workers, or both? 2 OTHER TYPES OF
WORKERS
3 BOTH

F_B5h Does this facility provide... 1 YES All facilities

2 NO
Incontinence care

F_B5h1_1 Is this service provided by paid facility employees, other 1 FACILITY EMPLOYEES F_B5h = 1
types of workers, or both? 2 OTHER TYPES OF
WORKERS
3 BOTH

F_B5i Does this facility provide... 1 YES All facilities

2 NO
Transportation to medical or dental appointments

F_B5i1_1 Is this service provided by paid facility employees, other 1 FACILITY EMPLOYEES F_B5i = 1
types of workers, or both? 2 OTHER TYPES OF
WORKERS
3 BOTH

F_B5j Does this facility provide... 1 YES All facilities

2 NO
Transportation to stores and elsewhere
F_B5j1_1 Is this service provided by paid facility employees, other 1 FACILITY EMPLOYEES F_B5j = 1

38
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

types of workers, or both? 2 OTHER TYPES OF

WORKERS
3 BOTH

F_B5k Does this facility provide... 1 YES All facilities

2 NO
Personal laundry

F_B5k1_1 Is this service provided by paid facility employees, other 1 FACILITY EMPLOYEES F_B5k = 1
types of workers, or both? 2 OTHER TYPES OF
WORKERS
3 BOTH

F_B5l Does this facility provide... 1 YES All facilities

2 NO
Linen laundry services

F_B5l1_1 Is this service provided by paid facility employees, other 1 FACILITY EMPLOYEES F_B5l = 1
types of workers, or both? 2 OTHER TYPES OF
WORKERS
3 BOTH

F_B5m Social services counseling is counseling related to obtaining 1 YES All facilities
and keeping benefits provided by programs such as 2 NO
Supplemental Security income, Social Security, and
Medicaid.
Does this facility provide...

Social services counseling

F_B5m1_1 Is this service provided by paid facility employees, other 1 FACILITY EMPLOYEES F_B5m = 1
types of workers, or both? 2 OTHER TYPES OF

39
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

WORKERS
3 BOTH

F_B5n Case management is generally a process of assessment, 1 YES All facilities

planning, and facilitation of options and services for an 2 NO
individual. Does this facility provide . . .

Case management

F_B5n1_1 Is this service provided by paid facility employees, other 1 FACILITY EMPLOYEES F_B5n = 1
types of workers, or both? 2 OTHER TYPES OF
WORKERS
3 BOTH

F_B5o Does this facility provide... 1 YES All facilities

2 NO
Occupational therapy

F_B5o1_1 Is this service provided by paid facility employees, other 1 FACILITY EMPLOYEES F_B5o = 1
types of workers, or both? 2 OTHER TYPES OF
WORKERS
3 BOTH

F_B5p Does this facility provide... 1 YES All facilities

2 NO
Physical therapy

F_B5p1_1 Is this service provided by paid facility employees, other 1 FACILITY EMPLOYEES F_B5p = 1
types of workers, or both? 2 OTHER TYPES OF
WORKERS
3 BOTH

40
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_B5q Does this facility provide... 1 YES All facilities

2 NO
Transportation to a sheltered workshop, work training
program or supported employment

F_B5q1_1 Is this service provided by paid facility employees, other 1 FACILITY EMPLOYEES F_B5q = 1
types of workers, or both? 2 OTHER TYPES OF
WORKERS
3 BOTH

F_B5r Does this facility provide... 1 YES All facilities

2 NO
Transportation to an education program

F_B5r1_1 Is this service provided by paid facility employees, other 1 FACILITY EMPLOYEES F_B5r = 1
types of workers, or both? 2 OTHER TYPES OF
WORKERS
3 BOTH

F_B5_cable Does this facility offer... 1 YES All facilities

2 NO
Cable TV access in resident (rooms/apartments/rooms and
apartments).

F_B5_tele Does this facility offer... 1 YES All facilities

2 NO
A landline telephone in resident (rooms/apartments/rooms
and apartments).

F_B5_int Does this facility offer... 1 YES All facilities

2 NO
Internet access in resident (rooms/apartments/rooms and

41
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

apartments).

F_B5s Does this facility have public internet access elsewhere in 1 YES All facilities
the facility? 2 NO

F_B5_assist_a HAND R SHOWCARD 1 YES All facilities

Do any of the residents use... 2 NO

An amplifier for the telephone. Please do not include a

hearing aid.

F_B5_assist_b A telecommunications device for the deaf, or TDD, is an 1 YES All facilities
electronic device for text communication via a telephone 2 NO
line, used when one or more of the parties has hearing or
speech difficulties. It is also referred to as a TTY or
teletype. Do any of the residents use...

TDD, TTY or teletype? Please do not include a hearing aid.

F_B5_assist_c Do any of the residents use... 1 YES All facilities

2 NO
Any other types of assistive listening devices. Please do not
include a hearing aid.

F_B5_assist_d Do any of the residents use... 1 YES All facilities

2 NO
Signaling devices -- that is, devices that can visually alert
the hearing impaired person to auditory signals that may not
be heard.

F_B5_assist_e A communication board is another type of device sometimes 1 YES All facilities
used by individuals with speech or hearing impairments. 2 NO

42
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

They can be plain boards that you erase or have pictures or

words on them that the individual points to as a means of
communication.
Do any of the residents use...

A communication board

F_B5_assist_f Do any of the residents use... 1 YES All facilities

2 NO
Other equipment for people with hearing or speech
impairments?
Please do not include a hearing aid.

F_B7a HAND R SHOWCARD 1 PROVIDING A All facilities

CENTRAL LOCATION
Do you or other staff assist residents with medications in WHERE MEDICATIONS
any of the following ways? Please tell me the numbers that ARE STORED PRIOR TO
apply from this card. ADMINISTRATION TO
RESIDENTS
2 PROVIDING
MEDICATION REMINDERS,
FOR EXAMPLE,
PROMPTING THAT IT IS
TIME TO TAKE
MEDICATIONS
3 DELIVERING PRE-
PACKAGED UNIT DOSES
4 HELPING WITH,
ADMINISTRATION FOR
EXAMPLE, OPENING
THE BOTTLE AND
HANDING THE RESIDENT

43
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

THE CORRECT DOSE

5 HELPING THE
RESIDENT TAKE THE
MEDICINE, FOR
EXAMPLE,PUTTING IT IN
THEIR MOUTH AND
HANDING THE RESIDENT
A GLASS OF WATER
6 PROVIDING
OVERSIGHT AND CUEING
TO MAKE SURE THE
RESIDENT ACTUALLY
TAKES THE MEDICATION
7 ADMINISTERING
DROPS, TOPICAL
OINTMENTS, ETC.
8 ADMINISTERING IV
MEDICATIONS
9 ADMINISTERING
INJECTIONS
10 OTHER TYPE OF
ASSISTANCE
11 FACILITY DOES
NOT ASSIST RESIDENTS
WITH MEDICATIONS

F_B7b HAND R SHOWCARD 1 RN F_B7a = 3 or 4

2 LPN
Who passes or hands the residents their prescription 3 CERTIFIED MEDICATION
medications? Passing medications includes the delivery of AIDE, MEDICATION
pre-packaged doses or opening the bottle and handing the SUPERVISOR, OR
resident the correct dose. Please tell me the numbers that MEDICATION TECHNICIAN
apply from this card.

44
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

4 PERSONAL CARE AIDE

5 OWNER, DIRECTOR,
ASSISTANT DIRECTOR,
OR MANAGER
6 OTHER

F_B8 Who administers prescription medications to the residents? 1 RN F_B7a = 5, 7, 8,

Administering medications includes placing the medication 2 LPN or 9
in residents' mouths and handing them glasses of water, 3 CERTIFIED MEDICATION
giving injections, giving IV medications, or applying AIDE, MEDICATION
prescription topical ointments and creams. Please tell me SUPERVISOR, OR
the numbers that apply from this card. MEDICATION TECHNICIAN
4 PERSONAL CARE AIDE
5 OWNER, DIRECTOR,
ASSISTANT DIRECTOR,
OR MANAGER
6 OTHER

F_B8_lic (Is this person a licensed nurse, certified medication aide, 1 YES (F_B8 is not only
medication supervisor, or medication technician/Are each of 2 NO 1, not only 2, and
these individuals licensed nurses,certified medication aides, not only 1 and 2)
medication supervisor, or medication technician)? AND (F_B7a =
any selection of
5, 7, 8 or 9.)

F_B9 Does the facility have a pharmacist or doctor, either on staff 1 YES All facilities
or through a contract with an outside service provider, 2 NO
review the medications that residents receive for
appropriateness?

F_B10 Does this (residential care) facility ever use physical 1 YES All facilities
restraints such as lap buddies, posey restraint, bed rails, or 2 NO

45
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

Gerry chairs?

F_B11 Do facility staff regularly give drugs to any resident to control 1 YES All facilities
behavior or to reduce agitation? This includes drugs 2 NO
prescribed by a physician or other medical provider.

F_B12Intro The next series of questions are about charges to the 1 CONTINUE All facilities
resident.

F_B12a How is the base rate structured? Does this facility offer a flat 1 FLAT BASE RATE All facilities
base rate or is there a rate that varies by disability or 2 BASE RATE VARIES BY
services received? Do not include variations in charges by DISABILITY
room type or size.

F_B12b Can the residents obtain additional services, beyond the 1 YES All facilities
base rate, on a fee-for-service basis? 2 NO

F_B13 Is a security deposit required? 1 YES All facilities

2 NO

F_B14 Does this facility charge an entrance fee prior to moving in? 1 YES All facilities
2 NO

F_B15Intro The next questions are about the average monthly base rate All facilities
for (the room/the apartment/both the room and apartment) 1 CONTINUE
rent and the services.
IF NEEDED: If two people are living in the same room and
are related, please compute the average as if only one
person lived in the room.

F_B15a1 What is the average monthly base rate for a single individual 0..9995 F_ANEW1=4 &

46
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

living in a studio apartment (for a regular, non-Alzheimer’s F_S3a = 2

unit)?

F_B15a2 What is the average monthly base rate for a single individual 0..9995 F_ANEW1=4 &
living in a studio apartment for an Alzheimer’s unit. F_S3A or F_A58
=1
F_B15b1 What is the average monthly base rate for a single individual 0..9995 F_ANEW1=5 &
living in a 1-bedroom apartment (for a regular, non- F_S3a = 2
Alzheimer’s unit)?

F_B15b2 What is the average monthly base rate for a single individual 0..9995 F_ANEW1=5 &
living in a 1-bedroom apartment for an Alzheimer’s unit.? F_S3A or F_A58
=1
F_B15c1 What is the average monthly base rate for a single individual 0..9995 F_ANEW1=6 &
living in a 2-bedroom apartment (for a regular, non- F_S3a = 2
Alzheimer’s unit)?

F_B15c2 What is the average monthly base rate for a single individual 0..9995 F_ANEW1=6 &
living in a 2-bedroom apartment for an Alzheimer’s unit? F_S3A or F_A58
=1
F_B15c3 What is the average monthly base rate for a single individual 0..9995 F_ANEW1=7 &
living in a 3-bedroom apartment (for a regular, non- F_S3a = 2
Alzheimer’s unit)?

F_B15c4 What is the average monthly base rate for a single individual 0..9995 F_ANEW1=7 &
living in a 3-bedroom apartment for an Alzheimer’s unit? F_S3A or F_A58
=1
F_B15d1 What is the average monthly base rate for a single individual 0..9995 F_ANEW1=1&
living in a room designed for one person(for a regular, non- F_S3a = 2
Alzheimer’s unit)?

47
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_B15d2 What is the average monthly base rate for a single individual 0..9995 F_ANEW=1 &
living in a room designed for one person for an Alzheimer’s F_S3A or F_A58
unit? =1

F_B15e1 What is the average monthly base rate for a single individual 0..9995 F_ANEW1=2&
living in a room dssigned for two persons (for a regular, non- F_S3a = 2
Alzheimer’s unit)?

F_B15e2 What is the average monthly base rate for a single individual 0..9995 F_ANEW=2 &
living in a room designed for two persons for an Alzheimer’s F_S3A or F_A58
unit? =1

F_B15f1 What is the average monthly base rate for a single individual 0..9995 F_ANEW1=3 &
living in a room for three or more residents (for a regular, F_S3a = 2
non-Alzheimer’s unit)?

F_B15f2 What is the average monthly base rate for a single individual 0..9995 F_ANEW=3 &
living in a room for three or more residents for an F_S3A or F_A58
Alzheimer’s unit? =1

F_B16Intro HAND R SHOWCARD 1 CONTINUE All facilities

For the next questions, please tell me if the following
services provided by this facility are included in the base
rate or provided at an extra charge.

F_B16b Is assistance with activities of daily living included in the 1INCLUDED IN BASE RATE F_B5b=1
base rate or provided at an extra charge? 2 PROVIDED AT EXTRA
CHARGE

48
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_B16c Is assistance with a bath or shower at least once a week 1INCLUDED IN BASE RATE FB5c = 1
included in the base rate or provided at an extra charge? 2 PROVIDED AT EXTRA
CHARGE

F_B16d Are skilled nursing services included in the base rate or 1INCLUDED IN BASE RATE FB5d = 1
provided at an extra charge? 2 PROVIDED AT EXTRA
CHARGE

F_B16h Is incontinence care included in the base rate or provided at 1INCLUDED IN BASE F_B5h = 1
an extra charge? RATE
2 PROVIDED AT EXTRA
CHARGE
F_B16i Is transportation to medical or dental appointments included 1INCLUDED IN BASE F_B5i = 1
in the base rate or provided at an extra charge? RATE
2 PROVIDED AT EXTRA
CHARGE
F_B16o Is occupational therapy included in the base rate or provided 1INCLUDED IN BASE F_B5o = 1
at an extra charge? RATE
2 PROVIDED AT EXTRA
CODE ALL THAT APPLY CHARGE

F_B16p Is physical therapy included in the base rate or provided at 1INCLUDED IN BASE F_B5p = 1
an extra charge? RATE
2 PROVIDED AT EXTRA
CODE ALL THAT APPLY CHARGE

F_B17 Are privately hired nurses, aides, or private duty nurses 1 YES All facilities
permitted to provide services to residents? 2 NO

F_B18 How many meals are included in the base rate? 1 ONE MEAL PER DAY All facilities
2 TWO MEALS PER DAY

49
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

3 THREE MEALS PER DAY

4 NO MEALS PROVIDED

F_B19 Are residents required to eat during a scheduled meal time? 1 YES All facilities
2 NO
F_B20 Are residents required to eat meals in a specific location like 1 YES All facilities
a dining room? 2 NO

F_B21 Does this facility have residents who speak limited or no 1 YES All facilities
English? 2 NO

F_B22 How do staff communicate with these residents? 1 CAREGIVERS ALSO F_B21 = 1
SPEAK THEIR LANGUAGE
2 RELY ON FAMILY
MEMBERS TO
TRANSLATE
3 USE A TRANSLATION
SERVICE
4 NON-VERBAL CUEING/
HAND SIGNS/GESTURES
5 OTHER METHOD

F_C1_Intro INTERVIEWER: ARE YOU SPEAKING WITH THE... 1 HIGHEST RANKING All facilities
ADMINISTRATOR OR
DIRECTOR OF THE
RESIDENTIAL CARE
PORTION OF THIS
FACILITY
2 SOMEONE OTHER THAN
THE HIGHEST RANKING
ADMINISTRATOR OR
DIRECTOR OF THE

50
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

RESIDENTIAL CARE
PORTION OF THIS
FACILITY

F_C1 How long have you worked at this facility as the YEARS F_C1_Intro = 1
administrator or director? Please include the total time MONTHS
worked even if you have left the facility and then returned.

F_C2 How long, in total, have you worked at this and other YEARS F_C1_Intro = 1
residential care facilities or nursing homes in an MONTHS
administrative position?

F_C3 Do you have a certificate or license related to managing 1 YES All facilities
facilities for older people? 2 NO

F_C4 HAND R SHOWCARD 1 Owner or Operator F_C1_Intro = 2

2 Administrator, Manager,
What position(s) do you hold at this facility? or Director
3 Supervisor-in-charge
4 Wellness Director
5 Director of Nursing
6 Other

F_C4_OTH What other position do you hold at this facility? SPECIFY F_C3 = 6

F_C5 How long has the director or administrator worked at this SPECIFY F_C1_Intro = 2
facility as the administrator? Please include the cumulative
time worked even if they have left the facility and then
returned.

F_C6 Does the director or administrator have a certificate or 1 YES F_C1_Intro = 2

license related to managing facilities for older people? 2 NO

51
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

F_D1_Intro Please answer the last few questions about the highest 1 CONTINUE All facilities
ranking administrator or director of this residential care
facility.

F_D1 What is the gender of the director or administrator? 1 MALE All facilities
2 FEMALE

F_D2 HAND R SHOWCARD 1 18 - 29 All facilities

Please look at this card and tell me which range includes the 2 30 - 39
administrator or director’s age. 3 40 - 49
4 50 - 59
5 60 - 69
6 70 or older

F_D3 Is the administrator or director of Hispanic, Latino, or 1 YES All facilities

Spanish origin or descent? 2 NO

F_D4 HAND R SHOWCARD 1 WHITE OR CAUCASIAN All facilities

2 BLACK OR AFRICAN
Which of these groups best describes the administrator or AMERICAN
director? 3 ASIAN
4 NATIVE HAWAIIAN OR
You may select more than one category. OTHER PACIFIC
ISLANDER
5 AMERICAN INDIAN OR
ALASKA NATIVE

F_D5 What is the highest grade or level of education the 1 Less than high school All facilities
administrator or director completed? 2 High school graduate or
GED
Less than high school 3 Vocational, trade school,

52
 2010 National Survey of Residential Care Facilities (NSRCF)
Facility Questionnaire

Question number Facility Question item Code categories Facility Skip pattern
asked

High school graduate or GED or technical school graduate

Vocational, trade school, or technical school graduate 4 Some college
Some college 5 College graduate
College graduate 6 Post graduate
Post graduate

In the near future you may receive a telephone call from my

supervisor at RTI International. This call is designed to verify
F_D6a
the quality of my work and will only take a few minutes of 1 CONTINUE All facilities
your time.

F_D6 Thank you, those are all the questions for this Facility 1 CONTINUE All facilities
section of the interview.

53