First Adrian Manor Survey | adrianmanor.com

Nursing Care

Nursing Care Satisfaction: *

	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied
How satisfied are you that the care provided helps the resident to become or remain as alert and able as possible?
During atypical business hours (such as evenings and weekends), did you find the staff and care/services to be courteous and of a high quality respectively?

Nursing Services Timeliness: *

	Always	Most Often	Sometimes	Never
Does the nursing staff respond on a timely basis to the resident's call for assistance?
Are you satisfied that medications and treatments are properly administered?

Dietary Services

Food Tasty: *

	Always	Most Often	Sometimes	Never
Is the food well-prepared and tasty?

Food Satisfaction: *

	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied
Are you satisfied with the content and variety of the menu?
Are the meals appealing to the eye?
Are you satisfied with the manner in which residents are served or fed their meals?

Social Services

Social Services Satisfaction: *

	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied
Are you satisfied that all of your questions and concerns were addressed during the admission process?
Are you satisfied that the resident’s emotional, spiritual and psychosocial needs are being met?

Social Services Yes/No: *

	Yes	No
During admission, were you formally introduced to other key management and staff?
Regarding Resident’s Rights and Privacy (HIPAA); was Resident’s Rights and Privacy explained to you and/or your loved one(s) during the admission process?

Activities

Activities Satisfaction: *

	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied
How satisfied are you that the activities program meets the needs of your resident?

Activities Rating: *

	Excellent	Good	Fair	Poor
How would you rate the overall activities program?

Housekeeping and Maintenance

Housekeeping Frequency: *

	Always	Most Often	Sometimes	Never
Is the resident’s room kept clean and neat?
Are you satisfied with the cleanliness of the facility?
Does the facility have an odor problem?
Do you feel that the building and grounds are attractively maintained?

Laundry Services

Laundry Services Frequency:

	Always	Most Often	Sometimes	Never
Are you supplied with an adequate supply of clean and fresh linens?
Is your resident’s personal laundry done properly and timely? (Answer only if we do personal laundry).

Business Office / Administration

Business Services Frequency: *

	Always	Most Often	Sometimes	Never
Is the business office staff kind and courteous when addressing your needs or concerns?
Are your needs or concerns addressed in a timely manner and to your satisfaction?

Others

Hospice Yes/No:

	Yes	No
If applicable, were you given a choice regarding Hospice services?
Were you satisfied with other specialty services such as Dental, Podiatry, Vision etc?

Others Satisfaction: *

	Yes	No
Are you satisfied with the response of the staff to your concerns and complaints?

Others Rating: *

	Yes	No
In general, how would you rate the staff concerning the respect, compassion and kindness shown toward you and our resident?
In general, what is your overall rating of our nursing facility?

How long has (or was) your resident in our facility?

Other Comments:

Please write any other comments here:

	Excellent	Good	Fair	Poor
How would you rate the quality of nursing care?
Is the nursing staff attentive, respectful and pleasant?