"How Are We Doing" Survey

Our Center

Agree

Disagree

Don't know

The exterior of the building was attractive and well-kept

Residents’ rooms were clean

Therapy rooms, halls and public areas were clean

The overall décor of the center was attractive

The heating, air conditioning/ventilation was at a comfortable level

Our Staff

Agree

Disagree

Don't know

The center staff treated me/us with courtesy

I/we were greeted upon arrival

The staff was friendly and helpful overall

I/we were treated with dignity and respect

The staff was compassionate and caring

Confidentiality was respected

The staff made an effort to anticipate and address needs and concerns

The clinical staff was highly skilled

The rehab staff was highly skilled

Staff members were available and accessible

Staff interacted well with the residents

The staff showed a high level of professionalism

Our Care Services

Agree

Disagree

Don't know

The admission process was relatively easy

The resident’s care plan was clearly explained

Daily care routines were clearly explained

The staff was able to answer all of my/our care questions

I/we were kept informed of all changes in my/the resident’s condition

The attending physician was usually accessible or available

Residents have a variety of daily activities

The food was appetizing and of good quality

The dining area was clean and attractive

Housekeeping and laundry services met my expectations

Residents are safe and secure in the center

The overall care at the center is excellent

Are you a

Resident

Visitor

If visitor, what was the date and time of your visit?

Date:

Time:

Was this your first visit?

Yes

No

If visitor, what was the purpose of your visit?

Visiting a patient

Attending a patient conference

Touring for a potential placement

Touring for general information

Attending a professional meeting

Other:

Would you recommend our center to someone who required our services?

Yes

> No

Did any staff member(s) provide particularly excellent service?

> Yes

No

Name(s) of staff:

Are there any other comments you'd like to share with us?:

While completion of this section is optional, it is helpful for us to know who is completing this form so that we may properly address any concerns and give an appropriate response.

Name:

Address:

City:

State:

Zip:

Telephone:

Date: