Resident Name:

Your Name (individual filling out survey):

Date of Admission (optional):

Facility Admitted to:

Email:

1. Is the facility clean? yes no
      Comments:

2. Is the facility well maintained? yes no
      Comments:

3. Did the admissions person answer all of your questions and concerns? yes no
      Comments:

4. Was the admissions person easy to access by telephone?
    Did they answer your calls promptly? yes no
      Comments:

5. Has the manager been able to answer your questions?  Are they accessible? yes no
      Comments:

6. Is the staff friendly and courteous? yes no
      Comments:

7. Are the activities adequate? yes no
      Comments:

8. Is the meal service adequate? yes no
      Comments:

9. Are call lights answered promptly? yes no
      Comments:

10. Does the staff respect your privacy? yes no
      Comments:

11. Is the staff appearance professional? yes no
      Comments:

12. Have you met or ever spoken with the Regional Manager? yes no
      Comments:

13. Would you recommend the facility to others? yes no
      Comments:

14. Is there anything that you would like to see us do for you or your loved one?
      Comments: