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FAMILY SATISFACTION SURVEYInsert Facility NameWe are committed to providing your family member with quality services and facilities. Please take a moment to fill out this comment form to let us know how well we are meeting your expectations. The questions mirror those asked of families, as part of the Federal nursing facility survey/inspection process.After completing the form, you can drop it off at the facility on your next visit or put it in the mail. Our staff will assure the confidentiality of your responses. Please put an “X” in the column that best expresses your response to the question. Use the “I don’t know” column only for those questions marked with an XX. Additional comments can be added on page 2 to let us know how we can improve in areas where you are not completely satisfied.YesNoI don’t know (XX) 1Do you feel that staff treats your relative/friend with respect and dignity? 2Is there enough staff available in this facility to make sure that residents get the care and assistance they need without having to wait a long time?3XXDoes your resident receive the assistance with meals that they need?4XXDoes your resident receive the assistance with dressing and grooming that they need?5Does your resident have any chewing or eating problems, or mouth pain?6Does your resident have any tooth problems, gum problems or denture problems?7Have you ever notice any staff member being rough with, talking in a demeaning way at any residents?8If you have noticed staff treating a resident rough did you report this?9Do you know how to report this concern?10Is your resident able to have their belongings and/or furniture if they wish?11Has your resident had any belongings damaged or taken without permission?12Have you ever reported an item stolen from your resident?YesNoI don’t know (XX)13Is this a comfortable building in which to live?14Is this facility clean?15Has your relative/friend been moved to a different room with in the past several months?16Did you receive notice of explanation before the move?17Are you able to get money from your residents account at any time?18When your resident was admitted, did the staff tell you about how to apply for and use Medicaid or Medicare to pay for their stay?19Has there been a change in your resident’s condition with in the past several months?20Did the staff notify you promptly?21Does the facility honor preference and previous life routines (time to get up and go to sleep)?22Does the staff encourage your resident to attend activities and provide assistance to attend them?23Can you meet privately with your resident/friend?24Does the staff speak privately about your relative’s/friend’s medical or behavioral condition?Thank you! Please share any specific suggestions or compliments you might have. You do not need to give your name unless you wish to. We will use the responses to this survey to help us set our improvement goals for this next year. FAMILY SATISFACTION SURVEYADDITIONAL COMMENTS AND SUGGESTIONS________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________This form is generously shared by a NNFA colleagueJuly 2016 ................
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