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

Field	Information
Name:
Resident:
Relationship:
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

Category	Rating
Staff Responsiveness	⭐⭐⭐⭐⭐ ⭐⭐⭐⭐ ⭐⭐⭐ ⭐⭐ ⭐⭐ ⭐
Cleanliness	⭐⭐⭐⭐⭐ ⭐⭐⭐⭐ ⭐⭐⭐ ⭐⭐ ⭐⭐ ⭐
Meal Quality	⭐⭐⭐⭐⭐ ⭐⭐⭐⭐ ⭐⭐⭐ ⭐⭐ ⭐⭐ ⭐
Safety Measures	⭐⭐⭐⭐⭐ ⭐⭐⭐⭐ ⭐⭐⭐ ⭐⭐ ⭐⭐ ⭐
Social Activities	⭐⭐⭐⭐⭐ ⭐⭐⭐⭐ ⭐⭐⭐ ⭐⭐ ⭐⭐ ⭐
Medical Care	⭐⭐⭐⭐⭐ ⭐⭐⭐⭐ ⭐⭐⭐ ⭐⭐ ⭐⭐ ⭐
Communication	⭐⭐⭐⭐⭐ ⭐⭐⭐⭐ ⭐⭐⭐ ⭐⭐ ⭐⭐ ⭐
Facility Environment	⭐⭐⭐⭐⭐ ⭐⭐⭐⭐ ⭐⭐⭐ ⭐⭐ ⭐⭐ ⭐
Overall Satisfaction	⭐⭐⭐⭐⭐ ⭐⭐⭐⭐ ⭐⭐⭐ ⭐⭐ ⭐⭐ ⭐
Total

Comments/Suggestions

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.

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