Nursing Home Quality Form

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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