Please rate the QUALITY OF CARE or SERVICE PROVIDED by checking the circle with
the level which best reflects your satisfaction with our services. As this is a
multi-purpose evaluation, for rehabilitation patients and long-term care residents,
please rate only the areas or departments for which there has been contact during
the past quarter. If there has been no experience with a service, individual or
activity, select No Rating which means non applicable.
Sometimes
No Rating
No
Yes
Please select the name of the facility
1. The staff speaks privately (without being overheard) about my medical condition.
2. The facility staff encourages me to attend activities and provides assistance to attend them.
14. I received a copy of the Residents Bill of Rights upon admission.
15. I am informed of changes in my treatment.
16. Staff talks to me politely and does not yell or speak to me in a demeaning way.
13. Therapy services are timely and appropriate.
12. This facility a comfortable and clean building in which to live.
11. I am invited to participate in my care plan conferences.
10. Any belongings damaged, missing, or taken without permission?
9. Staff members treat me carefully and kindly when giving care.
8. I receive assistance with dressing and grooming including teeth, dentures, and oral hygiene that I need.
6. The noise level at night is minimal.
7. I am satisfied with meals and how the food is served.
5. There's enough staff available in this facility to make sure that I get the care and assistance I need without having to wait a long time.
4. Facility staff treats me with respect and dignity.
3. Call lights are answered in a timely manner.
Is there someone that you would like to recommend for recognition?
If so, please provide your name and telephone number.
If yes, what is their name?
Would you like someone from Management to give you a call?
If sometimes or no, please provide the name of the employee:
Position/Department they work in:
If sometimes or no, please provide the name of the employee:
Position/Department they work in:
17. I am satisfied with my Physician services.
18. The facility manages my personal funds.
19. If yes, I am provided a quarterly statement of what is in my account.
20. I would recommend this facility to my friends and family.