Survey Survey Application Name: (optional) : From which hospital were you admitted to our facility? : Did the staff maintain a kind, caring and considerate attitude toward residents, family and visitors? : Very SatisfiedSomewhat SatisfiedSomewhat DissatisfiedVery DissatisfiedNot applicable Was the staff approachable and professional at all times? Very SatisfiedSomewhat SatisfiedSomewhat DissatisfiedVery DissatisfiedNot applicable Did the staff take your concerns seriously? Very SatisfiedSomewhat SatisfiedSomewhat DissatisfiedVery DissatisfiedNot applicable Were daily tasks such as getting dressed, washed and making your bed completed in a timely fashion? Very SatisfiedSomewhat SatisfiedSomewhat DissatisfiedVery DissatisfiedNot applicable How satisfied were you with the food? Very SatisfiedSomewhat SatisfiedSomewhat DissatisfiedVery DissatisfiedNot applicable How satisfied were you with the temperature of the food? Very SatisfiedSomewhat SatisfiedSomewhat DissatisfiedVery DissatisfiedNot applicable How satisfied were you with the diversity of menu choices? Very SatisfiedSomewhat SatisfiedSomewhat DissatisfiedVery DissatisfiedNot applicable Were the recreation activities enjoyable and appropriate for you? Very SatisfiedSomewhat SatisfiedSomewhat DissatisfiedVery DissatisfiedNot applicable Were the therapy staff sensitive to your stamina/physical condition? Very SatisfiedSomewhat SatisfiedSomewhat DissatisfiedVery DissatisfiedNot applicable How satisfied were you with the physician services and were they available to meet your needs and questions? Very SatisfiedSomewhat SatisfiedSomewhat DissatisfiedVery DissatisfiedNot applicable How satisfied were you with the facility's interaction and involvement with family and friends? Very SatisfiedSomewhat SatisfiedSomewhat DissatisfiedVery DissatisfiedNot applicable Was the facility clean and odor free? Very SatisfiedSomewhat SatisfiedSomewhat DissatisfiedVery DissatisfiedNot applicable Was the facility quiet, especially at night? Very SatisfiedSomewhat SatisfiedSomewhat DissatisfiedVery DissatisfiedNot applicable How satisfied were you with the way you were informed about your medical / insurance benefits and co-payments? Very SatisfiedSomewhat SatisfiedSomewhat DissatisfiedVery DissatisfiedNot applicable Were you well prepared and informed about your discharge planning? Very SatisfiedSomewhat SatisfiedSomewhat DissatisfiedVery DissatisfiedNot applicable Were you satisfied by the Social Workers support and involvement? Very SatisfiedSomewhat SatisfiedSomewhat DissatisfiedVery DissatisfiedNot applicable Overall, what was your level of satisfaction with the facility. Very SatisfiedSomewhat SatisfiedSomewhat DissatisfiedVery DissatisfiedNot applicable Would you recommend the facility to others? YesNo If you could change something about the facility, what would that be? Do you have any comments or would you like to acknowledge a specific employee, incident, or department at the facility?
