Assisted Living Facility Name:
Facility Address: Unit # Zip:
Phone:  Email:

Date of Plan Creation:
Resident Name:
Room Number/Location:

1. Purpose of the Daily Routine Planner

The Daily Routine Planner is designed to help organize and structure the day for residents in the assisted living facility, ensuring that their physical, mental, and emotional needs are met in a personalized and meaningful way. It allows for a routine that balances independence and the support required for day-to-day living.

2. General Schedule Overview

Time of Day:

  • Morning: 6:00 AM – 11:00 AM
  • Midday: 11:00 AM – 2:00 PM
  • Afternoon: 2:00 PM – 6:00 PM
  • Evening: 6:00 PM – 9:00 PM
  • Night: 9:00 PM – 6:00 AM

3. Morning Routine

Time: 6:00 AM – 9:00 AM

  • Wake-Up Time:
  • Personal Hygiene (e.g., bathing, grooming):
  • Breakfast: 
     
    • Preferred Food Choices:
    • Dietary Restrictions:
  • Medication Administration:
    (list medication below)
    • Medication List:
  • Exercise or Physical Activity:
    (type of activity)
    • Preferred Activity:
  • Social Interaction:
    • Preferred Social Activities:

4. Midday Routine

Time: 11:00 AM – 2:00 PM

  • Lunch:
    • Preferred Food Choices:
    • Dietary Restrictions:
  • Rest Time or Napping:
    (if yes, duration):
  • Engagement in Activities:
    • Preferred Activity (e.g., crafts, reading, puzzles):
  • Medical Appointments or Health Checks (if applicable):
    • Appointment Details:
    • Medication Administration (if applicable):
    • Medication List:

5. Afternoon Routine

Time: 2:00 PM – 6:00 PM

  • Afternoon Snack:
    • Preferred Snack Choices:
  • Physical Activity or Exercise:
    • Preferred Activity:
  • Social Engagement (e.g., group activities, social time with staff or other residents):
  • Recreational or Creative Time:
    • Preferred Activity:
  • Medication Administration (if applicable):
    • Medication List:

6. Evening Routine

Time: 6:00 PM – 9:00 PM

  • Dinner:
    • Preferred Food Choices:
    • Dietary Restrictions:
  • Evening Relaxation (e.g., TV, listening to music, reading):
  • Personal Hygiene (e.g., washing up before bed):
  • Evening Medication Administration:
    • Medication List:
  • Preparation for Bed (e.g., turning off lights, adjusting room temperature, etc.):

7. Night Routine

Time: 9:00 PM – 6:00 AM

Bedtime:

Sleep Needs (e.g., blackout shades, room temperature preference, sleep assistance):

Night Medication Administration (if applicable):

Medication List:

Wake-Up Assistance:

Preferred Wake-Up Time:

8. Special Considerations

  • Preferred Comfort Measures (e.g., blanket, pillow preference):
  • Mood or Behavioral Support Needs (e.g., anxiety, stress management):
  • Cognitive Support Needs (e.g., reminders, communication needs):
  • Mobility Assistance Needs:
    (please describe):

9. Notes and Additional Instructions

Any special instructions, preferences, or concerns that should be taken into consideration:

10. Acknowledgment and Agreement

By signing below, the undersigned acknowledges that the daily routine has been discussed and agreed upon, and that it will be reviewed periodically to ensure it meets the resident’s needs.

Resident Name:
Signature:

*


Date:

Facility Representative Name:
Signature:

*


Date:

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