Nursing Home Evaluation Form

Name:	[Your Name]
Date:
Phone Number:
Email:

This document is designed to assess the quality and efficiency of services provided by our facility. Your feedback is invaluable in helping us maintain high standards of care and continuous improvement. Please complete the following sections based on your observations and experience.

For each aspect being evaluated, please use the following scale to provide your rating:

1 = Very Poor: Does not meet expectations at all, significant improvement needed.

2 = Poor: Below expectations, several areas need improvement.

3 = Average: Meets the basic standards but has room for enhancement.

4 = Good: Generally meets expectations with some minor issues.

5 = Excellent: Exceeds expectations with high standards maintained.

Section 1: Facility Cleanliness and Maintenance

Evaluating the cleanliness and maintenance of our facility ensures we provide a safe and welcoming environment for all residents. Please rate the following areas based on their appearance and upkeep.

Aspect	Rating (1-5)	Comments
Overall Cleanliness	5	Exceptionally clean and tidy
Room Condition
Common Areas
Outdoor Spaces
Sanitation Facilities

Section 2: Staff Professionalism and Behavior

Staff professionalism and behavior are crucial for a positive residence experience. This section helps assess how staff interactions support a dignified and respectful environment for our residents.

Aspect	Rating (1-5)	Comments
Courtesy of Staff	5	Staff are always polite and respectful
Responsiveness
Competence
Staff Appearance
Availability

Section 3: Resident Care and Wellbeing

This section focuses on the direct care and wellbeing of our residents, including medical attention, personal care, and emotional support. Your insights help us enhance the quality of life for those we serve.

Aspect	Rating (1-5)	Comments
Medical Care Quality	5	Excellent, with timely and professional treatment
Personal Care
Emotional Support
Activity Variety
Nutritional Quality

Section 4: Safety and Security

Safety and security are paramount in our facility. This section helps us verify that all safety measures are effective and that residents feel secure at all times.

Aspect	Rating (1-5)	Comments
Emergency Procedures	5	Well-documented and clearly communicated
Security Staff
Safety Drills Frequency
Equipment Maintenance
Resident Safety

Section 5: Administration and Management

Effective administration and management are key to a smoothly running facility. This section assesses the efficiency of administrative processes and overall management responsiveness.

Aspect	Rating (1-5)	Comments
Admission Process	4	Streamlined, but some paperwork delays
Staff Management
Complaint Resolution
Financial Transparency
Overall Satisfaction

Please complete each section with your honest feedback. Your input is essential for us to ensure our facility continues to meet the needs and expectations of our residents and their families. Thank you for your cooperation and time.