Nursing Home Quality Assurance Feedback Form

Thank you for taking the time to provide feedback on our nursing home services. Your input is invaluable in helping us maintain and improve the quality of care we provide to our residents. Please fill out this form honestly and thoroughly.

Personal Information (Optional):

Name:	[Respondent Name]
Relationship to Resident:	[Relationship to Resident]
Contact Information:	[Contact Information]

Facility Environment and Cleanliness:

Please rate the following aspects of the facility environment and cleanliness:

Aspect	Excellent	Good	Fair	Poor
Cleanliness of common areas
Condition of resident rooms
Overall appearance of the facility
Odor control
Maintenance of outdoor spaces

Staff Responsiveness and Communication:

Please rate the following aspects of staff responsiveness and communication:

Aspect	Excellent	Good	Fair	Poor
Promptness in addressing needs
Clarity of communication
Friendliness and approachability of staff
Availability of staff for assistance
Effectiveness of staff in resolving issues

Quality of Care:

Please rate the following aspects of the quality of care provided:

Aspect	Excellent	Good	Fair	Poor
Medication management
Assistance with activities of daily living
Medical care and treatment
Dietary services
Rehabilitation services

Additional Comments:

Please provide any additional comments or suggestions for improvement:

Thank you for your feedback. Your input will help us enhance the quality of care we provide to our residents.

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