Long-Term Care Facility Survey Checklist Form
Please complete this checklist to evaluate the overall condition and operations of the long-term care facility.
Overall cleanliness of the facility
*
1
2
3
4
5
Staff responsiveness to resident needs
*
1
2
3
4
5
Safety and security measures in place
*
Excellent
Good
Fair
Poor
Quality and variety of meals provided
*
Very Satisfied
Satisfied
Neutral
Dissatisfied
Medication management procedures
*
Always follow procedures
Usually follow procedures
Sometimes follow procedures
Rarely follow procedures
Resident engagement in activities
*
1
2
3
4
5
Facility environment (lighting, noise, temperature)
*
Very Comfortable
Comfortable
Somewhat Comfortable
Uncomfortable
Communication with residents and families
*
Excellent
Good
Fair
Poor
Input Table: Rate the following areas
*
Rows
Cleanliness
Safety
Comfort
Resident Rooms
1
2
3
Common Areas
4
5
6
Dining Areas
7
8
9
Additional comments or suggestions
Submit Survey
Should be Empty: