to the TESS
TESS-NH
INSTRUMENT MANUAL
DATE and TIME
Record the date and time of your observation. You should use the time that you begin
your observation. If you plan to use the TESS-NH as a measure of comparison across
sites keep the time standardized. Also, do not complete the TESS-NH during mealtimes,
if possible.
UNIT DESCRIPTION
Many facilities have multiple special care units to serve populations with different needs.
If there are four special care units within one facility you would complete the question as
follows:
UNIT__1__ (unit) of __4__ Total # of Units(units)
The goal of this question is to distinguish between multiple units.
Question A1. Type of unit:
There is tremendous diversity in what facilities consider Special Care Units (SCU), or in
how they care for persons with dementia in non-SCUs. This question is designed to
determine, on the most general level, what type of unit is being assessed.
A unit is defined as a geographically distinct area of a long-term care facility or a whole
facility which contains spaces for sleeping and public use.
Special Care Unit (segregated): The segregated SCU must be physically separated from
the rest of the facility by closed doors or the SCU is free-standing. Additionally, the
facility/unit must self-designate the unit as a specialized dementia care unit. In addition
to these two criteria, the unit must meet two of the three criteria described below:
1) The unit serves a population in which 75% or more of the residents have a
diagnosis of Alzheimer’s disease or related dementia.
2) The units programming and activities are dementia-specific.
3) The staff are trained in dementia care.
Special Care Unit (cluster): A distinct area (group of rooms) which is part of a larger,
non-specialized unit. It must designate itself as a specialized dementia care wing, cluster,
pod, etc. Additionally, it must meet criteria #1-3 explained in the SCU-segregated
definition.
Non Special Care Dementia Unit: Any unit not meeting the definition of the segregated
or cluster SCU, but serves at least 75% of persons with dementia. Ex. A separate (either
segregated or cluster) unit for persons with dementia that doesn’t provide dementia-
specific programming and activities and/or doesn’t provide staff training in dementia
care.
Other Unit, Mixed or Unspecified: Choose this category if the unit or site does not
meet the criteria for one of the three above. Examples: a hospital wing which serves
50% of persons with dementia and has some dementia programming. Or a long-term care
setting which has mentally ill and dementia residents in a congregate living situation
where some programming may be for persons with dementia. But, the unit is not
dementia specific and the large majority of residents served are not demented.
Question A2. Resident rooms on unit:
Private rooms are rooms designed to accommodate one bed. Thus, the number of rooms
should equal the total number of beds for this question. Semiprivate rooms are defined
as rooms that were designed to accommodate two beds. Count the number of rooms and
the number of beds (occupied and unoccupied). It is important to note that the number of
beds may vary in double rooms. For example, a room may be designed for two beds, but
is occupied by only one resident (and one bed). In this situation, you may need to ask
staff.
Rooms that accommodate three or more beds should be counted and the number of
beds should be totaled.
Question A3. Total rooms for unit: Add the number of rooms column of A2a, A2b,
and A2c to calculate the total number fo resident rooms on the unit.
Resident Capacity should equal the total number of beds available.
The number of residents sleeping on the unit today will likely equal the total number
of occupied beds. However, you will need to ask staff this question because residents
may be out of the unit for medical or personal reasons.
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PRIOR TO BEGINNING THE TESS-NH WALK-THROUGH
As you begin to make observations about the environment, begin listening for noises that
may be disruptive and potentially impact the environment. The last environmental
category (NOISES, questions 30 and 31) will ask you to judge noise level over the entire
observational time frame. Pay particular attention to the kinds of noises you hear, their
consistency and frequency. Similarly, identify the main television (if there is one) and
watch throughout your observational period to determine if it is on continuously for a
non-activity, if it is on for an activity, or if it is off during your entire observation.
Similarly, take note of odor of the unit when you first enter the SCU or study site.
Question number 9 will ask about odors. Because persons accommodate to odor over
time, your response to this question may not be accurate at a later time. In this case, first
impressions are very important.
UNIT AUTONOMY
Question 1: Nurses Station
Issue: This question relates to the autonomy of the SCU in comparison with other units
in the facility (if applicable). This question does not refer to non-nursing station work
areas such as desks or observation posts.
A nursing station is an area where medical records and medication administration records
(MARs) are kept. This area is primarily used as a work space for nurses and other staff.
Circle “2” if the nursing station does not serve other units.
Circle “1” if the nursing station is shared with other units.
Circle “0” if there is no nursing station.
Question 2: Provision for Paperwork
Issue: This question relates to space available for unit staff to complete paperwork.
Nursing Station: see definition of question 1
Separate Desk in Public Area: There is a designated desk in the public area (that may
or may not be in an alcove) that is used for staff paperwork. This desk is not used for
programmed activities, but only for staff. If this desk contains medical records and
MARs then it is defined a nursing station and would not be marked “yes”.
Counter/Work Area Combined with Other Area: Designated as a staff work area
where staff do most of their charting, but when staff are not using this area, it is used by
residents for different activities.
Enclosed Work Room: A room that is enclosed by a door that staff use to do
paperwork. However, this room does not contain medical records and MARs that would
meet the definition of a nursing station. Ex. If there is an enclosed office for nursing
staff and the office contains MARs and patient records, code yes for Nursing Station, but
no for Enclosed Work Room.
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Question 3: Unit Serves as Pathway
Issue: The goal of this question is to determine if there is increased traffic flow in the
unit as a result of the unit’s location within a larger facility. It is expected that such a
pathway will interfere with the physical environment by making it louder and more
difficult in terms of exit control. It may also interfere with a units autonomy. Similarly,
such a pathway may have programmatic concerns including difficulty engaging residents
in activities or increasing confusion among persons with dementia.
“Yes” if the unit has two doors in which staff and visitors use to go from one part of the
facility to another.
“No” If the unit does not serve as a pathway because it only has one entrance/exit to the
rest of the facility or if the unit is in no way attached to a larger facility (i.e. it is a house,
it is physically separate from the rest of the facility, etc.)
Question 4: Ability to provide services to residents
Issue: The goal of this question is to assess the ability to provide services to its’ residents
without using other parts of the facility.
Circle the correct response for the number of persons who engage in the eating, formal
activities, and bathing on the unit.
EXIT CONTROL
Question 5: Exit Disguise
Issue: The goal of this question is to determine what types of efforts have been made to
disguise exits from residents. It refers to the location of the door and its ability to be
recognized as a door.
“Yes” refers to the whole door and the door frame, and possibly (but not necessarily) the
surrounding area being treated so that it does not look like a door. (This does not include
just “painting out” the door the same color as the wall). It may also include the
intentional design of the unit to put the door in a place that is not easily accessible to
residents. The disguise must be deliberate.
“To Some Extent” indicates that at least part of the door is visible. Some attempts have
been made to disguise the door. For example, painting the door and frame as the same
color as the surrounding walls (only applicable if the rest of the doors in the facility are
not treated the same way). It may also include a fabric barrier in front of the door handle.
“No” refers to no efforts to disguise exits in any way.
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Question 6: Exit Monitoring
Issue: The purpose of this question is to assess how exiting the unit is monitored and
controlled. Do not include exits that lead to secured courtyards; that question will be
addressed later. Instead, consider all other possible exits from the unit. Circle “yes” to
all responses that apply.
6a. Number of Exits off of the unit: Count the number of exits that leave the unit,
excluding elevators and doors that lead to courtyards.
6b. Number of Elevators off of the unit: Count the number of elevators that can be
used to exit the unit.
6c. Locked Doors: Doors are locked if they limit the residents’ ability to physically
leave the unit. Circle “yes” if the exit is permanently locked or if the lock can be
disengaged by using some device such as a key, keypad, switch, etc.
If you circle “yes”, answer questions 6d-6f.
6d. Triggered Locking Device: Resident wears a device (often a band around the wrist
or ankle) that, when the resident approaches a door, the device triggers the door to lock.
You may have to ask staff if this system is in place; it may not be directly obvious.
6e. Keypad or Switch: In order to unlock the door, one must press a sequence of
numbers or letters on a keypad to disengage the lock. Or, the door may be unlocked by
flipping a switch located somewhere on the unit (near the door, at the nursing station,
etc.).
6f. Temporary Locks: There may be doors (excluding courtyard doors) that are
unlocked during the daytime and/or good weather. However, the staff may lock them at
night or when adverse weather conditions make it unsafe for residents to exit. Respond
“yes” if this occurs on this unit. You may need to ask a staff person; this is usually not
directly observable. When a lock is used only temporarily, it is not necessary to indicate
the type of locking device is being used.
ALARMS:
An alarm is a sound that occurs that informs staff of unit exiting.
6g. Doors Alarmed: Are doors alarmed to monitor resident exit?
If you circle “yes”, answer questions 6h-6j.
6h. Device Alarm: An alarm is sounded when a person wearing a device approaches an
exit or walks through an exit. You may need to ask staff if this is not directly observable.
If a resident approaches a door wearing such a device and the door locks and an alarm is
sounded, you would code “yes” for 3b and 3h.
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6i. Keypad Alarm: Code “yes” if the door is unlocked, and an alarm is sounded when
persons exit the unit without disengaging the alarm by using a keypad or switch.
6j. Alarm with All Entries and Exits: No matter what you do, an alarm will sound
when you enter or exit the unit. Remember to exclude courtyard exits.
MAINTENANCE
Question 7a-7d: Maintenance
Maintenance refers to loose handrails, broken door knobs, broken chairs, exposed wires
or extension cords, wheelchairs with missing parts, etc.
Rate the maintenance of the following areas: shared social spaces, halls, residents’
rooms, residents’ bathrooms.
CLEANLINESS
Question 8a-8d: Cleanliness
Cleanliness refers to dirty walls or floors, spills which are not cleaned up, indoor litter,
dust, etc. If a resident has just been bathed, there may be some water on the floor, but this
should be cleaned up before another resident is brought in to be bathed. If the spilled
water remains, you will code down. If the staff make an effort to clean the spills in a
timely manner, you should not consider this “uncleanliness”. Also, following mealtime,
there may be food on the floor. This should be cleaned up within an hour following
mealtime. Rate the cleanliness of the following spaces: shared social spaces, halls,
residents’ rooms, and residents’ bathrooms.
Question 9a-9b: Unpleasant Odors
Issue: While recognizing that on most units there will be incontinent residents, staff are
likely to quickly clean areas of the unit where these accidents occur. This question does
not address odors which are localized by residents who have not yet been clean, but is
concerned with odors in both public areas and residents’ rooms. It is important to survey
the entire unit (all public areas and most residents rooms) prior to responding to this
question.
SAFETY
Question 10a-10d. Floor Surface
This question addresses the degree to which the surface is highly waxed and slippery, and
whether the surface is uneven. Floor surfaces which are slippery are a hazard to the
residents. Also, changes in floor material can be a problem if the surfaces are not level
(i.e. if the carpet is higher than the tile floor, this rise could cause a foot to “catch” as one
moves from the tile to the carpet). This question is for all areas of the unit, including the
bathrooms.
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Question 11: Handrails
Issue: Handrails assist residents in moving through the unit, and can aid in rising from
the toilet. Do not count handrails in lounge/activity areas, as one would reasonably
expect furniture to be around the walls in this type of space. Do not count bumper
guards, as residents cannot easily hold onto them.
Rate hallways and bathrooms separately.
Question 11a. Hallways:
Extensive: if they are located on both sides of most halls.
Somewhat: if they are located on both sides of most halls or on one side of all halls.
Little or None: if handrails are largely absent.
Question 11b. Bathrooms:
Extensive: two handrails present on either side of the toilet to assist residents in sitting,
standing, and turning. Handrails placed behind the toilets are not considered helpful and,
thus, would not be counted as present.
Somewhat: there is one handrail placed on either side of the toilet to assist residents in
sitting, standing and turning.
Little or None: handrails are absent or there is one handrail placed behind the toilet.
LIGHTING
Question 12: Light Intensity
Issue: Lighting is a critical environmental feature which supports a variety of functional
activities. Because of age-related changes in eyesight, the older person needs almost
three times as much light as a 20 year old. Also, he/she is very sensitive to changes in
light levels and glare. Glare is usually a combination of light sources (either fixtures or
sunlight) and floor surface (usually hard, shiny floors).
This question addresses the light level in three areas of the unit: hallways, activity areas,
and resident rooms. You should consider intensity (glare and the evenness of the lighting
will be addressed in Q13 and Q14). In order to judge the intensity of the lighting think of
trying to read through the eyes of a 75 year old person.
You are asked to rate the light levels in three areas: hallways, activity areas, and residents
rooms. For multiple activity rooms, and hallways consider the rating that would best
represent most rooms.
*Turn on all of the available lights in the residents bedrooms before making an
assessment of the lighting for the next three questions.
Ample: Bright, illuminated. Intensity of light makes it easy to read in all areas of the
room.
Good: Lighting is basically good. It may be low in some areas. Reading would be easy
in most areas of this room/hallway.
Barely Adequate/Inadequate: Light intensity is low. Reading is difficult or impossible
in almost every area of this room.
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Question 13: Glare
Issue: The older eye is especially sensitive to glare. This question addresses surfaces
(particularly floors and walls, but also furniture surfaces) which are shiny and reflect light
(sunlight or from light fixtures). Glare tends to vary depending on the day, whether it is
sunny or not, and if there are many windows that allow sunlight into the unit.
A Little or None: there is little glare throughout the hallways, activity areas and resident
rooms.
In a Few Areas: there are some surfaces which are shiny and reflect light.
In Many Areas: glare is present throughout the halls, activity areas and/or resident
rooms.
Question 14: Even Lighting
Issue: In addition to intensity and glare, evenness of the light throughout the spaces is
important. The older eye is especially sensitive to pools of light and dark. Lighting
should be relatively even throughout the space, so that there is only moderate contrast
between areas which are brighter and those which are less bright. *Remember to turn on
the lights in the bedroom.
2: Lighting is even throughout the room
1: Lighting is even throughout most of this room. There may be corner where the
lighting is dim, creating a shadow.
0: Lighting is uneven throughout this room.
SPACE AND SEATING
Question 15: Chairs in Resident Rooms
Issue: Residents should have an opportunity to sit in their room without having to sit on
the bed. Count the number of rooms with chairs and divide this number by the total
number of rooms. If the room is a double room, two chairs should be provided to
accommodate both individuals.
Question 16: Unit Spaces
Issue: The goal of this question is to determine the number and types of different spaces
which are available to residents on the unit.
Type of Area:
The following definitions apply to the specific room types. Code “yes” if the unit has this
type of space.
Multi-purpose room: This room is used for multiple purposes often for formal activities
and dining. This type of room is common for smaller or renovated special care units in
which one room is used for all group gatherings.
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Activity room: This room is generally used for formal group activities. It may vary in
size depending on the size of the unit.
Dining room: This room is used exclusively for meals and snacks.
Lounge: This room is generally used for informal activities. It tends to be smaller (more
like a den or living room in your home). Activities that might go on in a lounge include
small family gatherings, television/video watching, small group gatherings, reading.
Some facilities call these rooms family rooms. It may also be a theme room for
reminiscing.
Alcove: Any widening of a hallway used for public seating and or activities. If the
widening occurs on one side only and if its depth is no more than the width of the
hallway, then it is an alcove. If its depth exceeds the width of the hallway, then it is a
room.
Other: If you have additional activity rooms, lounges, etc. use the 11f-11i and indicate
the type of room. This question does not imply that the room must be some other type of
room than has already been listed.
Exclusively for Unit: If access to the room/area is limited to the residents of the unit. If
the unit of interest is part of a larger unit, only respond “yes” if the area is primarily for
the unit residents, not the rest of the unit.
Seating Capacity: The count of available seating spaces within a given room. A chair
would allow one person to sit at a time. A couch would often allow 2-3 persons to sit
comfortably. Also, count empty spaces for wheelchairs (which require approximately 30”
X 48”). Piano benches also constitute available sitting space.
Example: an activity room contains four tables with four chairs per table. It also has a
loveseat and a chair. In addition, there is space for three additional wheelchairs to fit.
Thus, seating would total (4x4) + 2 + 1+ 3 = 22. You would enter this number under
seating category for the appropriate room.
Square Footage: In order to accurately measure the dimensions of a room, it is
recommended that a digital estimator be used. These can be purchased from Brookstone
#Y-14395. The cost approximately $45. In order to get the square footage, you take the
length of one side of a room (in feet) and multiply this number by the width (in feet) of
the room.
If you are unable to purchase the digital distance estimator, you can “step off” the room.
Many people have a step of approximately 3 feet. Or you can put one foot in front of
another and walk across the room with each step approximately 1 foot.
Adjacent Toilet: This question assesses the availability and accessibility of bathrooms
in public areas (if there is a public toilet for resident use available and in view adjacent to
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the different public areas). Respond yes if the doorway of the bathroom is no more than
eight feet from the public room the rater is observing.
Question 17: Positive Wandering
Issue: This question addresses opportunities for positive wandering. The goal is to create
a path which the resident can follow, which ideally provide the resident with a sense of
going somewhere. Also, allows for opportunities to sit and rest while wandering.
Question 17a:
Dead Ends: is defined as an end of a path that requires the person to turn around in a
space which is no wider than the path, or which leads to doors which the residents are not
supposed to go through (doors with alarmed or secured doors). If a facility has both dead
end paths and non-dead end paths, code for whichever is more prevalent.
ex. traditional nursing homes, with long halls that end with doors would be coded as
“dead end”. “L-shaped” halls can end in dead ends unless the end of the hall opens into
another room or to an unlocked courtyard.
No Dead Ends: means that either the paths lead directly into rooms or alcoves which are
wider than the path, or that they lead directly to other paths (such as intersecting
hallways).
ex. a circular pathway is not likely to lead to dead ends. A hallway which ends, but
opens into an activity area would not be considered a dead end.
Question 17b:
Places to Sit: seating must be on the path or in an alcove, but not in a separate room or
lounge.
No Places to Sit: no seating is provided along the wandering path
Question 18: Configuration of Rooms
Issue: This question relates to the ability of the unit to help orient the residents and guide
them to public areas. Plans which are more open, allowing easy visual access to public
areas are probably easier for residents (as opposed to residents having to read signs or
locate hidden areas). For the purposes of this question, a hallway only counts as a
“hallway” if it has walls on both sides.
No Hallways: is the appropriate response if the majority of bedrooms open up onto the
public areas.
Short Hallways: if bedrooms open up onto hallways which are approximately 40-50 feet
making it somewhat difficult to see public areas from the bedroom doors. The hallway
length is the length of 4 typical, side-by-side semi-private rooms.
Long Hallways: if the bedrooms open up to hallways that are more than 40-50 feet.
Public spaces are not visible or are very difficult to see from most of the resident rooms.
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If there are multiple hallways with different lengths, choose the one which is most
prevalent.
FAMILIARITY/HOMELIKENESS
Question 19: Homelike Atmosphere
Issue: Increased familiarity and non-institutional image for the unit can be achieved in
part through the types of furnishings and decorations used in the unit. Residential
appearance is enhanced through the use of non-institutional finishes and furnishings:
curtains, wallpaper, variety of furniture with texture, carpet or hard wood floors, lamps,
wall-hangings, bookshelves, etc.
Public Areas: defined as any room/area which is not a bedroom, and not solely for staff
use. i.e. activity areas, resident dining areas, hallways, lounges, common resident
bathrooms.
“Homelike” furnishings: defined as a variety of different types of furniture (particularly
chairs), pattern or visual texture in the fabric, use of fabric (may be plasticized) vs. vinyl
or Naugahyde, wood or veneer vs. plastic or laminate. Having the same style chair
throughout the dining room can be homelike, but this chair should not be in other areas
throughout the unit. Arrangement of the furniture (set at right angles to each other as
opposed to side by side) is also more residential.
“Other features”: which related to a homelike environment include wall treatments
(wall paper or border print as opposed to painted walls), floor treatment (not vinyl or
terrazzo), window treatments (curtains), and lighting (lamps and incandescent fixtures as
opposed to ceiling fluorescent fixtures).
Question 20: Kitchen Availability
Issue: A kitchen promotes familiarity and residential quality of the unit. This question is
concerned with the availability of the kitchen components, not resident use of these
components. Availability of kitchen components means there is an opportunity for use
and addresses the physical environment. Use of the kitchen components would constitute
a process measure; residents use of their physical environment.
2: a kitchen area is available and residents have access to its use. The kitchen should
have the following four components of a residential kitchen: sink, cooking appliance
(may include a stove or microwave), refrigerator, and counter space.
1: there are selected kitchen appliances available on the unit. For example, the unit has a
refrigerator available for resident use, but the unit does not have a cooking appliance.
0: there are no kitchen appliances available on the unit and the residents never have
access to any kitchen appliances.
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Question 21: Personalizing Residents’ Rooms
Issue: Personalization does more than just create a sense of personal space and territory.
It helps people to maintain a sense of identity. In order for the room to be considered
personalized, the room must have three personal pictures and/or momentos. The
momentos must vary (three cards from a granddaughter do not constitute
personalization). Additionally, the momentos and/or pictures must be placed in two
different locations. Items that are not considered to be personal include staff generated
cards and collages. The items should represent the individual and have meaning to the
individual. Could include various family photographs, their trophy from a fishing
tournament, quilts or bedspreads from home, knickknacks, etc. This does not include
personal furniture since non-institutional furniture is addressed in a previous question.
Count the number of rooms that meet the definition of personalization and divide by total
number of rooms in order to get the percentage.
Question 22: Non-Institutional Furniture
Issue: The presence of home-like, non-institutional furniture creates a more comfortable
environment for individuals. For this question, furniture may include bed, bureau or
dresser, wardrobe, table or chair. It is not essential that the furnishings actually be
brought from the specific individual’s home. What is important is that it looks home-like
and the attempt is made by the family OR facility to create a non-institutional bedroom.
Question 23: Resident Appearance
Issue: Resident appearance may be a good indicator of the degree to which staff respect
the residents and are supportive of their dignity. This measure of appearance reflects
process of care. Similarly, resident appearance can add or takes away from the overall
physical environment of the unit, thus reflecting a structural aspect of the special care
unit.
You are to determine if the residents are well groomed and if their appearance is
appropriate for the setting and time of day. Residents who are well groomed are clean,
their hair is combed, and their hands/nails are clean. Residents may have on a range of
clothing to meet their individual needs (sweatsuit or suit) and different styles of clothing
would be expected on a unit. Residents may/may not have on shoes depending on the
time of day. The most important things to remember is whether or not the resident
appearance adds or takes away from the physical environment.
2: if 75% or more of the residents are well groomed
1: if 25-75% of the residents are well groomed
0: less than 25% of the resients are well groomed
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VISUAL/TACTILE STIMULATION
Question 24: View of Courtyard
Issue: The goal of this question is to determine the extent and quality of views available
to residents. The view which is most immediate and visible from windows should be
considered. If there is a sizable courtyard or lawn, with a parking lot or brick wall on the
far side, consider the view to be a courtyard. Consider courtyard view from bedrooms
and public areas.
Definition of a Courtyard: A courtyard refers to outdoor spaces with natural green
elements (grass, bushes, flowers etc.) and a view of the sky (the walls around the
courtyard should not be taller than a one story building). An open vista refers to views of
greater than 100 yards.
In order to determine the percentage of rooms with courtyard/vista views:
(1) count the number of rooms (bedrooms or public areas)
(2) count the number of rooms meeting the definition for the courtyard or vista view
(3) divide the number of total rooms by the number of rooms with a courtyard/vista view
This should give you a percentage of the rooms with the courtyard/vista view. Question
Question 25a: Tactile Stimulation
Issue: People enjoy interacting with their environment often by picking up and carrying
things around. This is especially true for the dementia population. An environment
which provides ample opportunities for this may diminish residents desire to borrow
things from other residents. Art on the walls which invites residents’ touch is another
opportunity for sensory stimulation and exploration.
Extensively: opportunities for tactile stimulation are in several program areas and in
hallways
Quite a Bit: in at least one program area (but not several) and in hallways
Somewhat: only in a specific program area or only in hallways, but not both
None: nothing to pick-up or touch throughout the unit
Question 25b: Visual Stimulation
Issue: This question is designed to assess how much visual stimulation is provided
throughout the unit. Examples of visual stimulation include pictures, wall hangings,
display cases, patterned wallpaper. The objects of visual stimulation must be hung at eye
level in order to be considered.
Extensively: opportunities for visual stimulation are in several program areas and in
hallways
Quite a Bit: in at least one program area (but not several) and in hallways
Somewhat: only in a specific program area or only in hallways, but not both
None: nothing to look at or engage one’s visual attention throughout the unit
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ACCESS TO OUTDOORS
Question 26: Courtyard Accessibility
Issue: This question relates both to the accessibility of an outdoor space to the residents
and to the autonomy which residents have in reference to its use.
“3”: Residents have free access to a courtyard and the courtyard is adjacent to the unit.
The door(s) is/are not secured by a lock. If the door is locked only at night or during
inclement weather, the rater should still code “3.”
“2”: A courtyard is adjacent to the unit, but a staff (or family) member must accompany
the resident outside, or must unsecure a door which leads to the outside area.
“1”: A courtyard is available for resident use, but the courtyard is not adjacent to the
unit. Thus, residents must be guided to the courtyard and accompanied by family or staff.
“0”: There is no courtyard present.
Question 27: Courtyard Appearance and Functionality
Issue: Measuring the availability of a courtyard for resident use is important and
necessary of an overall assessment of an SCU. It is equally important to measure the
attractiveness (how inviting it is to use) and whether or not the courtyard is functional.
Question 27a:
Attractive: warm materials including wood and brick (not just white concrete
walkways), comfortable seating, varied plantings, shade, a barrier that is visually
appealing, bird feeders.
Question 27b:
Functional: seating available, walking paths, space for gardening, safe barrier (at least 8
feet or higher).
Very: If 75% or more of the above features are present.
Somewhat: If 30-75% of the above features are present
Not at all: If little or none of the above features are present
ORIENTATION/CUEING
Question 28: Cueing
Issue: This question refers to the units/facilities effort to help residents locate their
bedrooms, their bathrooms, and public areas independently.
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Questions 28a1-28g1:
RESIDENT ROOMS:
a) “1” if the majority of the residents bedroom doors are left open during waking hours.
b) “1” if the residents name is on the door. The lettering must be at eye level and at least
two inches high.
c) “1” if there is a current picture of the resident on or near the door(as he or she is now)
d) “1” if there is an old picture of the resident on or near the door(as he/she was years
ago)
e) “1” if there are objects of personal significance on or near the door. Objects may
include a photograph of a favorite pet or summer vacation spot. May also include a name
badge he/she used to wear, arts/crafts that are meaningful to this person.
f) “1” if there are room numbers on or near the door that are at least two inches high and
at eye level
g) “1” if the unit makes an effort to color code different rooms so that residents may
identify their room. A hall with all the same color doors, is not individualized for the
residents and would not count.
Questions 28a2-28c2:
RESIDENT BATHROOMS:
a) “1” if the residents bathroom door is left open most of the time and the commode is
visible from the resident’s bed
b) “1” if the residents bathroom door is left open most of the time, but the commode is
not visible from the resident’s bed
c) “1” if the residents bathroom door is kept closed, but there is a picture, graphic or sign
on the door to indicate the location of a bathroom.
Questions 28a3-28c3:
ACTIVITY AREA: any activity area available for residents to enter and provides
opportunities for sitting and socializing (may include a nursing station)
a) “1” if the activity area is visible (you can see into it) from the doorway of at least 50%
of the resident room doorways
b) “1” if a visual indicator such as an awning, statue, flag, or a nurses station (beside the
most frequently used activity area) is visible from the doorway of at least 50% of the
residents rooms. The goal of the visual indicator is to draw residents to the activity area
c) “1” if a directional sign (such as an arrow) or an identification sign (such as a name
sign) for the activity room is visible from at least 50% of the resident room doorways.
PRIVACY
Question 29: Privacy in Resident Rooms
Issue: Privacy is an important human need which is often limited in institutions. This
question addresses an individual’s opportunities for privacy in his/her bedroom. If all
rooms are private/non-shared, leave this question blank.
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Privacy Curtain: A curtain is usually hung from the ceiling of the room and separates
the beds from one another when pulled. If this is the only method used for privacy, code
“1” for Privacy Curtain and “0” for other.
Other: Any other type of measure used to secure privacy. Other types of privacy
measures include: solid partition such as a wardrobe, a movable wall barrier. Indicate in
the space provided any means of providing privacy in shared rooms and circle “1” for
“other”.
NOISES
Question 30: Television
Issue: The television can be disturbing as background noise especially if the television is
being used for non-activity purposes. Persons with dementia often cannot understand the
programs, and as a result may increase confusion. This question should be rated based on
your entire observation time-not only what is happening now.
2: The television was off all of the time.
1: The television was on some of the time for a non-activity. For example, the
television was turned on to a channel which does/is not showing a program that is
relevant to the individuals in the home. If the television was on all of the time, but was
only briefly used for programming, code 1.
0: The television was on all of the time and was not being used for an activity. A major
concern is that staff may turn on the television to suit their purposes, not the residents.
6: The television was on all of the time for an activity. The activity should be“ageappropriate” activity such as watching an old black and white movie. After the activity
ended, the television was turned off.
9: No television present on the unit.
Question 31: Noise
Issue: The older person, and the person with dementia in particular, have a difficult time
screening out background noise. This skill is necessary to facilitate concentration on a
task or conversation with someone. Additionally, loud and consistent background noises
can be a source of frustration and confusion for residents residing on the unit.
Record noises you have heard throughout your entire observation period completing the
TESS-NH.
Not at all: During your entire observation period you have heard no noises of this type.
Sometimes: During your entire observation period you heard this noise periodically.
Constantly or high intensity: During your entire observation period you heard this
noise constantly OR intermittently, but with high intensity.
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OVERALL PHYSICAL ENVIRONMENT
Question 32. This question addresses your opinion of the overall physical environment.
In making this decision consider all factors related to the physical environment that have
already been answered previously. Circle a response 1-10.
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