Free Nursing Home Performance Evaluation Form Template
Nursing Home Performance Evaluation Form
Please rate each aspect on a scale from 1 to 5, with 1 representing the lowest rating and 5 representing the highest rating. Assign a score based on the performance observed or experienced, considering the quality, effectiveness, and satisfaction level. Aim to provide an accurate assessment that reflects the performance of the nursing home across various categories.
Facility Information
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Nursing Home Name: |
[Your Company Name] |
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Location: |
[Your Company Address] |
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Date of Evaluation: |
[Evaluation Date] |
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Evaluator(s): |
[Evaluator's Name] |
1. Staffing:
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Aspect |
Rating (1-5) |
Comments |
|---|---|---|
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Adequacy of nursing staff (RN, LPN, CNA, etc.) |
4 |
Sufficient staff present during evaluation. |
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Competency and training of staff |
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Staffing levels during day and night shifts |
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Communication and collaboration among staff |
2. Resident Care:
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Aspect |
Rating (1-5) |
Comments |
|---|---|---|
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Quality of medical care |
4 |
Residents received prompt and appropriate medical attention. |
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Assistance with activities of daily living (ADLs) |
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Medication management |
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Responsiveness to resident needs |
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Social and recreational activities |
3. Facility Environment:
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Aspect |
Rating (1-5) |
Comments |
|---|---|---|
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Cleanliness and hygiene |
5 |
Facility was clean and well-maintained throughout. |
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Maintenance of building and grounds |
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Safety features (e.g., handrails, call bells) |
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Accessibility for residents with mobility issues |
4. Regulatory Compliance:
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Aspect |
Yes/No |
Comments |
|---|---|---|
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Compliance with state regulations |
Yes |
No major violations observed during evaluation. |
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Compliance with federal regulations |
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Accreditation status (if applicable) |
5. Communication:
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Aspect |
Rating (1-5) |
Comments |
|---|---|---|
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Communication between staff and residents |
4 |
Staff were communicative and respectful towards residents. |
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Communication between staff members |
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Communication with families/guardians |
6. Quality Improvement:
Identify areas for improvement and develop action plans:
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7. Overall Evaluation:
Write the overall evaluation and summarize the strengths and areas for improvement:
Overall Rating (1-5): 4
Summary of Strengths:
Effective communication, quality resident care, cleanliness, and safety.
Summary of Areas for Improvement:
Medication management procedures, communication with families, and enhancing recreational activities.
Evaluator:
[Evaluator's Name]
[Date]
