Free Nursing Home Quality of Life Evaluation Template
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
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1 |
2 |
3 |
4 |
5 |
|---|---|---|---|---|
|
Poor |
Below Average |
Average |
Above Average |
Excellent |
General Information
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Field |
Information |
|---|---|
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Date of Evaluation: |
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Resident: |
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Room Number: |
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Evaluator: |
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Relationship to Resident: |
Evaluation
|
Aspect |
Score |
Comments |
|---|---|---|
|
Physical Well-being |
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Emotional Well-being |
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Social Engagement |
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Recreational Activities |
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Quality of Care |
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Staff Responsiveness |
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Facility Cleanliness |
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Meal Quality and Variety |
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Safety and Security |
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|
Overall Satisfaction |
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|
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!
