Nursing Home Quality of Life Evaluation

Please take a few moments to provide honest and constructive feedback. Please rate each aspect of your experience on a scale from 1 to 5, with 1 being Poor and 5 being Excellent. Use the comments column to provide additional details or suggestions for improvement.

Rating Scale

1	2	3	4	5
Poor	Below Average	Average	Above Average	Excellent

General Information

Field	Information
Date of Evaluation:
Resident:
Room Number:
Evaluator:
Relationship to Resident:

Evaluation

Aspect	Score	Comments
Physical Well-being
Emotional Well-being
Social Engagement
Recreational Activities
Quality of Care
Staff Responsiveness
Facility Cleanliness
Meal Quality and Variety
Safety and Security
Overall Satisfaction
Total Score

Your feedback is greatly appreciated and will help us enhance the quality of life for all residents in our nursing home facility. Thank you for your participation!

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