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Assisted Living Care Plan Form Template

Create a personalized care plan for residents in assisted living facilities.

Creating a well-structured care plan can be tough when you want to ensure each resident's needs are met. This assisted living care plan template helps you outline the specific preferences, goals, and care requirements for individuals in assisted living settings. With this tool, you can improve care delivery, enhance communication among staff, and foster a more personalized experience for residents, ensuring compliance with regulations and improving overall satisfaction. Explore the template now and simplify your planning process.

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Resident full name
Date of birth
Primary language
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Primary emergency contact full name
Relationship to resident
Primary emergency contact phone
Primary emergency contact email
Do you have a legal representative or power of attorney (POA)?
Yes
No
Unsure
Primary physician or clinic contact (name and phone)
Diagnoses and relevant medical history
Allergies (drug, food, environmental)
Medication management
Self-manage
Self-manage with reminders
Staff administer
Family supplies; staff administer
Not applicable
Advance directive or DNR on file
Yes
No
Unsure
Mobility status
Independent
Supervision
Minimal assistance
Moderate assistance
Full assistance
Not applicable
Transfers (bed/chair) assistance level
Independent
Supervision
Minimal assistance
Moderate assistance
Full assistance
Not applicable
Toileting and continence needs
Continent, independent
Needs reminders/scheduled toileting
Incontinent - uses briefs
Incontinent - toileting program
Catheter/ostomy
Not applicable
Room or environmental safety considerations (e.g., clutter, lighting)
Fall risk level
Low
Moderate
High
Unknown
Cognitive status
Intact
Mild impairment
Moderate impairment
Severe impairment
Fluctuating
Unknown
Behavior concerns observed
None observed
Agitation
Anxiety
Depression
Aggression
Sundowning
Exit seeking
Other
Please Specify:
Known triggers and effective calming strategies
Communication needs and supports
None
Hearing impairment
Vision impairment
Speech impairment
Uses hearing aids
Uses glasses
Uses dentures
Interpreter needed
Diet type
Regular
Low sodium
Diabetic/consistent carb
Renal
Cardiac/low fat
Mechanical soft
Pureed
Thickened liquids
Other
Please Specify:
Food allergies or intolerances
Meal assistance level
Independent
Reminders
Setup only
Partial assistance
Full assistance
Not applicable
Current pain level
No pain
Mild
Moderate
Severe
Unable to report
Preferred wake time
Activity interests
Please Specify:
Additional notes for care team
Vital signs monitoring frequency
Daily
Weekly
Monthly
With symptoms only
Per physician order
Not required
I confirm the information provided is accurate to the best of my knowledge.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
Signer full name (type to sign)
Signature date
Signer role
Resident
Family/Representative
Staff
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Paper art illustration showcasing a care plan form for assisted living services and templates.

When to use this form

Use this template when you admit a new resident, revise services after a fall or medication change, or update care following a hospital discharge. It helps administrators, nurses, and caregivers capture needs, risks, and preferences in one place and assign clear tasks. Start with recent assessments; you can reference the Home health assessment form and summarize findings to guide daily support. For clinical follow-up, align planned interventions with notes from a Nursing visit report form. The outcome is a focused plan that staff can deliver consistently, families can understand, and you can review during care conferences to show progress and adjust supports.

Must Ask Assisted Living Care Plan Questions

  1. What diagnoses, risks, and recent changes should we monitor?

    This identifies conditions and red flags that drive your priorities, such as fall risk, diabetes, or wandering. It keeps the team focused on early warning signs and timely escalation.

  2. Which ADLs and IADLs can the resident do independently, and where is assistance needed?

    Clear ability levels let you set the right supports, from prompts to full hands-on help. It also informs staffing and adaptive equipment choices to reduce injury.

  3. What is the current medication list, schedule, and monitoring requirements?

    Accurate meds and times reduce errors and missed doses, and they define vital checks or side-effect watch points. You can track time for med passes and wellness checks with the Home care timesheet form.

  4. What are the resident's daily routines, preferences, and personal goals?

    Knowing sleep, meal, bathing, and activity preferences improves comfort and cooperation. Personal goals make care person-centered and help you measure meaningful progress.

  5. Who is on the care team, and how will we communicate and document visits?

    Listing roles, contacts, and visit frequency prevents gaps and duplication. Capture aide credentials and contacts with the Home care aide registration form so you know who is authorized to deliver each task.

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