{"product_id":"activity-assessment-form-for-nursing-homes-cms-aligned-fillable-pdf-color-and-b-w-1","title":"Activity Assessment Form for Nursing Homes, CMS Aligned Fillable PDF, Color and B\u0026W","description":"\u003cp\u003eA 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.\u003c\/p\u003e\u003cp\u003eThe 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.\u003c\/p\u003e\u003cp\u003eWHAT IS INSIDE (8 pages, US Letter and A4)\u003cbr\u003ePage 1: Resident profile and assessment type (admission, quarterly, annual, significant change, re-admission), care setting, sources of information, interview status, assessor\u003cbr\u003ePage 2: Life history and personal profile (work, family, faith, music, pets, routines, strengths, dislikes and triggers)\u003cbr\u003ePage 3: Daily routine preferences, interview questions from MDS 3.0 Section F (F0400) with a rating grid\u003cbr\u003ePage 4: Activity preferences, interview questions from MDS Section F (F0500) with a rating grid, plus an interest list with source tags\u003cbr\u003ePage 5: Abilities, needs and supports, using MDS Sections B and C items (hearing, speech, vision, cognition and interview status)\u003cbr\u003ePage 6: Staff observation for residents who cannot be interviewed (MDS F0700 and F0800) and F679 situations to consider\u003cbr\u003ePage 7: Person-centered activity plan with measurable goals, approaches, type, frequency and staff\u003cbr\u003ePage 8: Participation log, plan review, reassessment types and sign-off with a credentials line\u003c\/p\u003e\u003cp\u003eCOLOR AND BLACK-AND-WHITE\u003cbr\u003e- Color version for screen use and color printing\u003cbr\u003e- Black-and-white ink-saver version with light grey bars and no dark fills, made for copiers and low-ink printing\u003cbr\u003e- Both versions have the same 8 pages and the same fillable fields\u003c\/p\u003e\u003cp\u003eFILLABLE AND PRINTABLE\u003cbr\u003e- Over 420 fillable fields: text boxes, check boxes, rating buttons and drop-down lists\u003cbr\u003e- Type on a computer or tablet in a PDF reader, or print and write by hand\u003cbr\u003e- Clear, plain layout with large check boxes, built to photocopy well\u003c\/p\u003e\u003cp\u003eGOOD TO KNOW\u003cbr\u003e- 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\u003cbr\u003e- No physical item is shipped\u003cbr\u003e- 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\u003cbr\u003e- Do not enter resident information into a file you store on an unsecured device. Follow your facility's privacy rules\u003cbr\u003e- Not medical or legal advice, and not a guarantee of survey compliance\u003cbr\u003e- Designed by BeingBrightStudio\u003c\/p\u003e","brand":"BeingBrightStudio","offers":[{"title":"Default Title","offer_id":67985420943635,"sku":null,"price":4.99,"currency_code":"USD","in_stock":true}],"thumbnail_url":"\/\/cdn.shopify.com\/s\/files\/1\/0978\/8732\/2387\/files\/0g6H8Xzxg0.jpg?v=1794294706","url":"https:\/\/www.activitydirectorspayactivitydirectors.com\/products\/activity-assessment-form-for-nursing-homes-cms-aligned-fillable-pdf-color-and-b-w-1","provider":"Activity Directors Pay Activity Directors","version":"1.0","type":"link"}