Free Nursing Home Resident Satisfaction Evaluation Template
Nursing Home Resident Satisfaction Evaluation
Please take a few moments to complete this evaluation honestly and thoughtfully.
For each question, indicate your level of satisfaction by indicating the appropriate score based on the rating scale provided below. Feel free to provide additional comments or suggestions in the space provided at the end of the evaluation.
Resident Information
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Field |
Information |
|---|---|
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Resident's Name: |
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Date of Evaluation: |
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Room/Unit Number: |
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Length of Stay: |
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Age: |
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Contact Information: |
Rating Scale
|
Score |
Meaning |
Details |
|---|---|---|
|
1 |
Very Dissatisfied |
Experience fell far below expectations. |
|
2 |
Dissatisfied |
Experience was below expectations and needs significant improvement. |
|
3 |
Neutral |
Experience was neither satisfactory nor unsatisfactory. |
|
4 |
Satisfied |
Experience met expectations, but could be improved. |
|
5 |
Very Satisfied |
Experience exceeded expectations, highly satisfactory. |
Evaluation
|
Aspect |
Questions |
Score |
|---|---|---|
|
Quality of Care |
How satisfied are you with the care provided by staff? |
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Are your medical needs attended to promptly? |
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Facilities |
Are the facilities clean and well-maintained? |
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Do you feel safe and secure within the facility? |
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Staff Interactions |
How would you rate the friendliness of the staff? |
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Do staff members listen and respond to your concerns? |
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Amenities |
Are the amenities (e.g., recreational areas) satisfactory? |
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Do you have access to the amenities you need? |
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Meal Services |
Are you satisfied with the quality of meals provided? |
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Are dietary preferences and restrictions accommodated? |
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Overall Satisfaction |
How satisfied are you overall with your living experience? |
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Overall Rating |
Additional Comments/Suggestions
Your feedback is greatly appreciated and will help us enhance our services to better meet your needs. Thank you for your participation!
