Free Nursing Home Quality Assurance Feedback Form Template
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):
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Name: |
[Respondent Name] |
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Relationship to Resident: |
[Relationship to Resident] |
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Contact Information: |
[Contact Information] |
Facility Environment and Cleanliness:
Please rate the following aspects of the facility environment and cleanliness:
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Aspect |
Excellent |
Good |
Fair |
Poor |
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Cleanliness of common areas |
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Condition of resident rooms |
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Overall appearance of the facility |
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Odor control |
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Maintenance of outdoor spaces |
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Staff Responsiveness and Communication:
Please rate the following aspects of staff responsiveness and communication:
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Aspect |
Excellent |
Good |
Fair |
Poor |
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Promptness in addressing needs |
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Clarity of communication |
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Friendliness and approachability of staff |
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Availability of staff for assistance |
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Effectiveness of staff in resolving issues |
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Quality of Care:
Please rate the following aspects of the quality of care provided:
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Aspect |
Excellent |
Good |
Fair |
Poor |
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Medication management |
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Assistance with activities of daily living |
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Medical care and treatment |
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Dietary services |
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Rehabilitation services |
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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.
