CAHPS NursingHome Survey

®

CAHPS Nursing Home Survey: Long-Stay Resident Instrument

CAHPS Nursing Home Survey – Long-Stay
Resident Instrument (With Instructions)
Instructions for Vendor........................................................... 1
Instructions for Interviewer .................................................... 1
Introductory Script and Questions ........................................ 2
Appendix: Showcards With Printed Response Options..... 11

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CAHPS Nursing Home Survey: Long-Stay Resident Instrument

Instructions for Vendor


The scripts provided in this document use the questions from the CAHPS
Nursing Home Survey – Long-Stay Resident Instrument.



If you plan to add your own items to this instrument, insert them just
before Item Number 39, which begins the "About You" section.



All questions should include a “REFUSED” response option, which can be
on the interviewer’s manual notation sheet. Unless otherwise noted,
“REF” responses should follow the same skip pattern as the “NO”
response option.



Please be aware that you may need approval from an Institutional Review
Board (IRB) in order to conduct this survey. Regardless of whether you
need IRB approval, you must get the respondent’s consent to participate.

Instructions for Interviewer


Interviewer instructions appear in [UPPERCASE LETTERS ENCLOSED
IN BRACKETS].



Text in UPPERCASE LETTERS should not be read aloud. For example,
“REF” answer categories appear in uppercase and should not be read to
the respondent, but may be used for coding a response.



Interviewers should read aloud all text that appears in bold, lowercase
letters. Other lowercase text is optional but recommended.



Interviewers should emphasize text that is underlined.

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Introductory Script and Questions
AFTER LOCATING RESIDENT, INTRODUCE SELF & BRIEFLY
INTRODUCE SURVEY
Hello, my name is {INTERVIEWER NAME} and I was hoping you’d have
some time to talk to me today about how things are going here for you.
(IF NEEDED: We’re doing a survey to learn about the care that nursing
home residents receive and would like your help.)
Would you like to participate in this survey?

 Yes
 Yes, but at a later time
 No
IF R AGREES, GO TO A PRIVATE LOCATION TO CONDUCT INTERVIEW.
IF R DOES NOT HAVE TIME TO PARTICIPATE IN INTERVIEW NOW,
ARRANGE AN APPOINTMENT TO GO BACK LATER.
IF NOT, THANK R FOR TIME AND LEAVE.
Before we start, let me tell you a few things about this survey.
The goal of this survey is to learn about the care that nursing home
residents receive in this nursing home and to improve the quality of
care in nursing homes.
If you agree to take part, we would ask you some questions about your
satisfaction with your nursing home care. This interview should take
approximately 20 minutes. Your participation in this study is
completely voluntary. No matter whether you decide to complete the
interview or refuse to participate, your care here will not be affected in any
way.
You can skip over any questions you don’t want to answer and you can
stop participating at any time.
All of your answers are completely confidential. Your name won’t be
connected to your answers in any way. No one at the nursing home will
know what you said.
By participating in this survey, you will help us develop better ways of
assessing nursing home quality. This may benefit residents in the future.
Do you have any questions before we start?

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[ANSWER ANY QUESTIONS, THEN GO TO QUESTION 1.]

[HAND R SHOWCARD 1: 0-10]
Now let’s talk about how you feel about things at this nursing home and
how you feel about the care you get. Remember, when you answer, you
can use any number from 0 to 10, where 0 is the worst possible and 10
is the best possible.
1.

First, what number would you use to rate the food here at this
nursing home?
_______ (0-10)

2.

Do you ever eat in the dining room?
1
2

3.

 YES
 NO IF NO, GO TO QUESTION 4

When you eat in the dining room, what number would you use to
rate how much you enjoy mealtimes?
_______ (0-10)

4.

What number would you use to rate how comfortable the
temperature is in this nursing home?
_______ (0-10)

5.

Now, think about all the different areas of the nursing home. What
number would you use to rate how clean this nursing home is?
_______ (0-10)

6.

What number would you use to describe how safe and secure you
feel in this nursing home?
_______ (0-10)

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7.

Now, think about all the different kinds of medicine that help with
aches or pain. This includes medicine prescribed by a doctor, as
well as aspirin and Tylenol. Do you ever take any medicine to help
with aches or pain?

 YES
2
 NO IF NO, GO TO QUESTION 10

1

8.

What number would you use to rate how well the medicine worked
to help with aches or pain?
_______ (0-10)

9.

What number would you use to rate how well the staff help you
when you have pain?
_______ (0-10)

10. What number would you use to rate how quickly the staff come
when you call for help?
_______ (0-10)
11. Do the staff help you get dressed, take a shower, or go to the toilet?

 YES
2
 NO IF NO, GO TO QUESTION 13
1

12. What number would you use to rate how gentle the staff are when
they're helping you?
_______ (0-10)
13. What number would you use to rate how respectful the staff are to
you?
_______ (0-10)
14. What number would you use to rate how well the staff listen to you?
_______ (0-10)

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15. What number would you use to rate how well the staff explain things
in a way that is easy to understand?
_______ (0-10)
16. Overall, what number would you use to rate the care you get from
the staff?
_______ (0-10)
17. Overall, what number would you use to rate this nursing home?
_______ (0-10)
[HAND R SHOWCARD 2: YES/NO/SOMETIMES]
For the next questions, you can answer yes, no, or sometimes.
18. Is the area around your room quiet at night?

 YES
 NO
3
 SOMETIMES
1

2

19. Are you bothered by noise in the nursing home during the day?

 YES
 NO
3
 SOMETIMES
1

2

20. If you have a visitor, can you find a place to visit in private?

 YES
 NO
3
 SOMETIMES
1

2

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21. Do you visit a doctor for medical care outside the nursing home?

 YES
 NO
3
 SOMETIMES
1

2

22. Do you see any doctor for medical care inside the nursing home?

 YES
 NO
3
 SOMETIMES
1

2

[OBSERVATIONAL SCREENER: IS R ABLE TO MOVE AROUND ALONE - NOT
IN WHEELCHAIR?]
1
2

 YES IF YES, GO TO QUESTION 26
 NO
23. If you wanted to, can you turn yourself over in bed without help from
another person?

 YES IF YES, GO TO QUESTION 26
 NO
3
 SOMETIMES
1

2

24. Are you ever left sitting or laying in the same position so long that it
hurts?

 YES
 NO
3
 SOMETIMES
1

2

25. Are you able to move your arms to reach things that you want?

 YES
 NO IF NO, GO TO QUESTION 28
3
 SOMETIMES
1

2

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26. We’d like to find out about whether you can reach the things you
need in your room. Can you reach the call button by yourself?

 YES
 NO
3
 SOMETIMES
1

2

27. Is there a pitcher of water or something to drink where you can
reach it by yourself?

 YES
 NO
3
 SOMETIMES
1

2

28. Do the staff help you dress, take a shower, or bathe?

 YES
2
 NO IF NO, GO TO QUESTION 30
1

29. Do the staff make sure you have enough personal privacy when you
dress, take a shower, or bathe?

 YES
 NO
3
 SOMETIMES
1

2

30. Can you choose what time you go to bed?

 YES
 NO
3
 SOMETIMES
1

2

31. Can you choose what clothes you wear?

 YES
 NO
3
 SOMETIMES
1

2

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32. Can you choose what activities you do here?

 YES
 NO
3
 SOMETIMES
1

2

33. Are there enough organized activities for you to do on the
weekends?

 YES
 NO
3
 SOMETIMES
1

2

34. Are there enough organized activities for you to do during the
week?

 YES
2
 NO
3
 SOMETIMES
1

[HAND R SHOWCARD 3: DEFINITELY NO/PROBABLY NO/PROBABLY
YES/DEFINITELY YES]
For the next question, you can answer definitely no, probably no,
probably yes, or definitely yes.
35. Would you recommend this nursing home to others?

 DEFINITELY NO
 PROBABLY NO
3
 PROBABLY YES
4
 DEFINITELY YES
1

2

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[HAND R SHOWCARD 4: OFTEN/SOMETIMES/RARELY/NEVER]
Now I’d like you to use this list of answer choices – often, sometimes,
rarely, or never.
36. How often do you feel worried – often, sometimes, rarely, or never?

 OFTEN
 SOMETIMES
3
 RARELY
4
 NEVER
1

2

37. How often do you feel happy – often, sometimes, rarely, or never?

 OFTEN
 SOMETIMES
3
 RARELY
4
 NEVER
1

2

[HAND R SHOWCARD 5: EXCELLENT/VERY GOOD/GOOD/FAIR/POOR]
38. In general, how would you rate your overall health – excellent, very
good, good, fair, or poor?

 EXCELLENT
 VERY GOOD
3
 GOOD
4
 FAIR
5
 POOR
1

2

[HAND R SHOWCARD 6: 0-10]
These next questions are about you.
39. First, we want to know how you feel about your life now. Use any
number from 0 to 10 where 0 is the worst possible and 10 is the best
possible. What number would you use to rate your life now?
_______ (0-10)

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40. In what year were you born?
_____________ (YEAR)
41. What is the highest grade or level of school that you have
completed?

 8th grade or less
 Some high school, but did not graduate
3
 High school graduate or GED
4
 Some college or 2-year degree
5
 4-year college graduate, or
6
 More than 4-year college degree?
1

2

42. Are you of Hispanic or Latino origin or descent?

 YES, HISPANIC OR LATINO
 NO, NOT HISPANIC OR LATINO

1
2

43. What is your race? (IF NEEDED: Would you say you are... )

 White
 Black or African-American
3
 Asian
4
 Native Hawaiian or other Pacific Islander
5
 American Indian or Alaska Native
6
 Other (Please print)
1

2

________________________

44. [INDICATE GENDER]
1
2

 MALE
 FEMALE

45. [ASK IF NOT OBSERVED] Do you currently have a roommate?
1
2

 YES
 NO

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Appendix: Showcards With Printed Response Options

(Cards begin on next page)

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10

Best possible

9
8
7
6
5
4
3
2
1
0

Worst possible
Showcard #1

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Yes
No
Sometimes

Showcard #2

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Definitely No
Probably No
Probably Yes
Definitely Yes
Showcard #3

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Often
Sometimes
Rarely
Never

Showcard #4

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Excellent
Very Good
Good
Fair
Poor
Showcard #5

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10

Best possible

9
8
7
6
5
4
3
2
1
0

Worst possible
Showcard #6

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