Does the resident: 

Appear depressed or anxious (e.g., sad, teary, non-communicative, anxious movements) 

Appear socially withdrawn, isolated, fatigued, not eating  

Appear to lack emotional affect, short tempered, easily annoyed 

Does staff recognize expressions, indications of distress, or behaviors and respond through a person-centered approach to care? 

Does the resident appear to exhibit hallucinations (e.g., hearing voices or seeing things not present)? 

Does the resident appear to exhibit any physical expressions of distress directed towards others - Hitting, striking out at others, kicking, pushing, scratching, and grabbing 

Does the resident appear to exhibit any verbal expressions of distress directed towards others -  threatening others, screaming at others, cursing at others, crying 

Does the resident appear to exhibit any other expressions of distress not directed toward others - physical such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, sounds that are distressing to other residents, constant vocalizations 

Wandering, ambulating in and out of resident’s rooms, rummaging in other resident’s belongings 

Appear angry, frustrated, combative, confrontational 

How do staff interact with resident(s) during these occurrences?