My Nursing Home / Short Term Rehab Experience Resident Survey
Share your experiences and help us understand what matters most to you as a resident. Your responses are confidential and voluntary.
Resident Survey
About You
1. How long have you lived in this nursing home?
Less than 6 months
6 months to 1 year
1-3 years
More than 3 years
2. Do you have a roommate?
Yes
No
3. Do you attend Resident Council meetings?
Yes, regularly
Sometimes
No, I choose not to.
I did not know there was a Resident Council
Ratings
4. Overall, how would you rate this nursing home?
1 = Very Poor
1
2
3
4
5 = Excellent
5
1 is 1 = Very Poor, 5 is 5 = Excellent
5. How would you rate your daily care (help with bathing, dressing, toileting, and medications)?
1 = Very Poor
1
2
3
4
5 = Excellent
5
1 is 1 = Very Poor, 5 is 5 = Excellent
6. How would you rate the food services overall?
1 = Very Poor
1
2
3
4
5 = Excellent
5
1 is 1 = Very Poor, 5 is 5 = Excellent
7. How would you rate housekeeping and laundry services?
1 = Very Poor
1
2
3
4
5 = Excellent
5
1 is 1 = Very Poor, 5 is 5 = Excellent
8. How would you rate your privacy and room environment (noise, space, visitors, roommates)?
1 = Never Meets my needs
1
2
3
4
5 = Always meets my needs
5
1 is 1 = Never Meets my needs, 5 is 5 = Always meets my needs
9. How would you rate activities offered and ways to spend your time?
1 = Never Meet my Interests
1
2
3
4
5 = Always Meet My Interests
5
1 is 1 = Never Meet my Interests, 5 is 5 = Always Meet My Interests
10. How often do you feel listened to when you raise a concern or ask for something?
1 = Almost Never
1
2
3
4
5 = Almost Always
5
1 is 1 = Almost Never, 5 is 5 = Almost Always
11. How safe do you feel speaking up about problems or complaints?
1 = Not Safe at All
1
2
3
4
5 = Very Safe
5
1 is 1 = Not Safe at All, 5 is 5 = Very Safe
12. How much choice do you have in your daily routine (when to wake up, eat, shower, go to bed)?
1 = Very Little Choice
1
2
3
4
5 = A lot of Choice
5
1 is 1 = Very Little Choice, 5 is 5 = A lot of Choice
13. Do you feel you have enough spending money (Personal Needs Allowance)?
1 = Strongly Disagree
1
2
3
4
5 = Strongly Agree
5
1 is 1 = Strongly Disagree, 5 is 5 = Strongly Agree
Food Follow-Up (Optional)
What are the biggest problems with the food? (Check all that apply)
Food is cold or not the right temperature
Food does not taste good
Not enough choices
My order is wrong
Food arrives late
Portions are too small
Special diet or preferences are not followed
Staff/service during meals is poor
Meals are repetitive
Other
How often does this happen?
Almost every meal
A few times a week
Once in a while
Which meal is usually the biggest problem?
Breakfast
Lunch
Dinner
Snacks
Varies
Is there anything else you want us to know about the food?
Your Voice
14. What matters most to you in your daily life here?
15. If you could change one thing about living here, what would it be?
16. If you could speak directly to lawmakers in Connecticut, what would you want them to know about life in a nursing home?
Submit Survey
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