Activity Assessment Form for Nursing Homes, CMS Aligned Fillable PDF, Color and B&W

A fillable 8-page Activity Assessment Form for activity directors, life enrichment coordinators and activity therapists in nursing homes, memory care, assisted living and skilled nursing. Use it to plan person-centered activities at admission, at every quarterly review, and whenever a resident's condition changes.

The interview questions use the wording of MDS 3.0 Section F (F0400, F0500, F0700, F0800) and the hearing, vision, mood and cognition items come from MDS Sections B and C. Situations and approaches are taken from CMS State Operations Manual Appendix PP, F679. Each page names its source. It is aligned with those documents. It is a planning tool and not an official CMS or MDS form. Always follow your facility policy and your state rules.

WHAT IS INSIDE (8 pages, US Letter and A4)
Page 1: Resident profile and assessment type (admission, quarterly, annual, significant change, re-admission), care setting, sources of information, interview status, assessor
Page 2: Life history and personal profile (work, family, faith, music, pets, routines, strengths, dislikes and triggers)
Page 3: Daily routine preferences, interview questions from MDS 3.0 Section F (F0400) with a rating grid
Page 4: Activity preferences, interview questions from MDS Section F (F0500) with a rating grid, plus an interest list with source tags
Page 5: Abilities, needs and supports, using MDS Sections B and C items (hearing, speech, vision, cognition and interview status)
Page 6: Staff observation for residents who cannot be interviewed (MDS F0700 and F0800) and F679 situations to consider
Page 7: Person-centered activity plan with measurable goals, approaches, type, frequency and staff
Page 8: Participation log, plan review, reassessment types and sign-off with a credentials line

COLOR AND BLACK-AND-WHITE
- Color version for screen use and color printing
- Black-and-white ink-saver version with light grey bars and no dark fills, made for copiers and low-ink printing
- Both versions have the same 8 pages and the same fillable fields

FILLABLE AND PRINTABLE
- Over 420 fillable fields: text boxes, check boxes, rating buttons and drop-down lists
- Type on a computer or tablet in a PDF reader, or print and write by hand
- Clear, plain layout with large check boxes, built to photocopy well

GOOD TO KNOW
- Digital download: one zip file with four PDFs (US Letter and A4, each in color and black-and-white) and a Read Me First page. Unzip before you open the PDFs
- No physical item is shipped
- Fillable fields work best in Adobe Acrobat Reader or a similar PDF app. Check that your app saves typed entries before you use it for real records
- Do not enter resident information into a file you store on an unsecured device. Follow your facility's privacy rules
- Not medical or legal advice, and not a guarantee of survey compliance
- Designed by BeingBrightStudio