Free Nursing Home Evaluation Form Template
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.
