Facility Information
Please fill out this form to register your community with Artisan Senior Placement
* Required
Facility Name
*
Your answer
Facility Address
*
Your answer
Address (line 2)
Your answer
City, State
*
Your answer
Zip Code
*
Your answer
Email
*
Your answer
Website
Your answer
Phone (xxx-xxx-xxxx)
*
Your answer
Fax Number (xxx-xxx-xxxx)
Your answer
Facility Care Type
*
Retirement
Assisted Living
Secured Memory Care
Skilled Nursing
Other:
Required
Room Types
*
Semi-Private- Shared Bathroom
Private Room- Shared Bathroom
Private Room- Private Bathroom
Studio Suite
1 Bedroom Private Suite
2 Bedroom Private Suite
3 Bedroom Private Suite
Required
Rate ($) Range- Semi-Private- Shared Bath
Your answer
Rate ($) Range- Private Room- Shared Bath
Your answer
Rate ($) Range- Private Room- Private Bath
Your answer
Rate ($) Range- Studio Suite
Your answer
Rate ($) Range- 1 Bedroom Suite
Your answer
Rate ($) Range- 2 Bedroom Suite
Your answer
Rate ($) Range- 3 Bedroom Suite
Your answer
2nd Person/Same Room
Your answer
Security Fee Amount
Your answer
Ambulation and Transfer Accepted
Independent
Frail or Slow
Fall History
Wanders
Standby Assistance
1-Person Transfer
2-Person Transfer
Hoyer or Sit/Stand on Admission
Hoyer or Sit/Stand lift only for current residents
Incontinence Needs Accepted
Offers Toileting Program
Bladder Incontinence
Bowel Incontinence
Foley
Special Diets
Low Sugar
Mechanical Soft
Pureed Diet
Thickened Liquids
Smoking/Alcohol
Smokers Welcome
Alcohol Allowed
Clear selection
Pets
Dogs Allowed
Cats Allowed
Other:
Clear selection
Professional Staff Available
*
Registered Nurse on Staff
Licensed Practical Nurse on Staff
Certified Nuirsing Aids on Staff
Physical Therapist
Occupational Therapist
Other:
Required
Staffing Patterns
Live-in Caregivers
24-Hour Awake Staff
Shift Workers
Staffing Ratio- Day
Your answer
Staffing Ratio- Night
Your answer
Cognitive Levels Accepted
Alert/ No Dementia
Mild Memory Loss
Moderate Memory Loss
Advanced Memory Loss
Behaviors Accepted
Anxiety/Agitation
Depression/Withdrawn
History of Verbal Aggression
History of Physical Aggression
History of Refusing Care
Wandering
History of Elopement
History of Paranoia/Hallucinations/Delusions
Health Related Care and Services
Oxygen Assistance
C-Pap Assistance
Medication Management
Insulin Dependent Diabetes (Self Administered)
Insulin Dependent Diabetes (Staff Administered)
Glucose Monitoring by Staff
Anticoagulant Therapy Injections by Staff
Feeding Tube
Wound Care
Hospice Care
Colostomy Care
Amenities Offered
Regularly Scheduled Activities
Fitness Center
Optional Dining
Secure Courtyard
Waking Paths
Beautician Services
Happy Hour
Are you a Licensed Medicaid Facility?
Yes
No
Clear selection
What is the Accepted Spend Down Periods for Medicaid?
2+Years Private Pay
1+ Year Private Pay
6+ Months Private Pay
Direct Medicaid
Other:
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