Free Nursing Home Quality Form Template
Nursing Home Quality Form
Please fill out the form accurately and completely. Rate each aspect of care and service based on your observations and experiences using the rating scale provided. Check the appropriate box for your rating. Provide additional comments or suggestions as needed in the designated section.
Personal Information
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Field |
Information |
|---|---|
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Name: |
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Resident: |
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Relationship: |
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Date: |
Rating Scale
|
Rating |
Meaning |
Description |
|---|---|---|
|
1 star |
Poor |
Performance significantly below expectations, requiring improvement |
|
2 stars |
Below Average |
Performance below expectations, with notable areas needing improvement |
|
3 stars |
Average |
Performance meeting basic expectations, with room for improvement in some areas |
|
4 stars |
Above Average |
Performance consistently meeting or exceeding expectations, with minor areas for improvement |
|
5 stars |
Excellent |
Exceptional performance consistently exceeding expectations, demonstrating high proficiency |
Quality Assessment
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Category |
Rating |
|---|---|
|
Staff Responsiveness |
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Cleanliness |
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Meal Quality |
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Safety Measures |
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Social Activities |
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Medical Care |
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Communication |
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Facility Environment |
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Overall Satisfaction |
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Total |
Comments/Suggestions
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No. |
Details |
|---|---|
Thank you for taking the time to complete this form. Your feedback is valuable to us and will aid in improving our services.
