Nursing Home Internal Evaluation Questionnaire
Please complete this questionnaire to help us assess and improve the quality of care and services in our nursing home.
Evaluator's Full Name
*
First Name
Last Name
Department or Area Being Evaluated
*
Please Select
Resident Care
Dining Services
Housekeeping
Maintenance
Recreation/Activities
Administration
Other
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please rate the following aspects of the nursing home:
*
Rows
Excellent
Good
Fair
Poor
Cleanliness of facilities
1
2
3
4
Staff professionalism
5
6
7
8
Resident safety
9
10
11
12
Response to resident needs
13
14
15
16
Quality of meals
17
18
19
20
Medication management
21
22
23
24
How would you rate the overall quality of care provided to residents?
*
1
2
3
4
5
Are residents treated with dignity and respect?
*
Always
Most of the time
Sometimes
Rarely
Is the environment safe and free from hazards?
*
Yes
No
Not sure
Are there adequate recreational and social activities for residents?
*
Yes
No
Not sure
Have you observed any areas in need of improvement?
Cleanliness
Meal quality
Staffing levels
Resident engagement
Communication
Other
Additional comments or suggestions for improvement
Submit Evaluation
Should be Empty: