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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