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ASSIGN
RESIDENT SATISFACTION SURVEY

001

FRIENDLINESS OF ACTIVITY STAFF

 
 
 
 
 
 
 
 
 
 
 
 

002

AVAILABILITY OF ACTIVITIES

 
 
 
 
 
 
 
 
 
 
 
 

003

APPROPRIATENESS OF ACTIVITIES PROVIDED

 
 
 
 
 
 
 
 
 
 
 
 

004

ONE-TO-ONE ROOM VISITS

 
 
 
 
 
 
 
 
 
 
 
 

005

EXPLANATION OF RESIDENTS RIGHTS

 
 
 
 
 
 
 
 
 
 
 
 

006

COURTESY OF THE ADMISSIONS COORDINATOR

 
 
 
 
 
 
 
 
 
 
 
 

007

EXPLANATION OF SERVICES PROVIDED

 
 
 
 
 
 
 
 
 
 
 
 

008

VARIETY OF FOOD SELECTION

 
 
 
 
 
 
 
 
 
 
 
 

009

PROFESSIONAL APPROACH OF DIETARY STAFF

 
 
 
 
 
 
 
 
 
 
 
 

010

QUALITY OF FOOD

 
 
 
 
 
 
 
 
 
 
 
 

011

TIMELINESS OF MEALS

 
 
 
 
 
 
 
 
 
 
 
 

012

PRESENTATION OF MEALS

 
 
 
 
 
 
 
 
 
 
 
 

013

HANDLING OF COMPLAINTS

 
 
 
 
 
 
 
 
 
 
 
 

014

PAIN MANAGEMENT

 
 
 
 
 
 
 
 
 
 
 
 

015

OVERALL RATING

 
 
 
 
 
 
 
 
 
 
 
 

016

RECOMMENDATIONS

 
 
 
 
 
 
 
 
 
 
 
 

017

COURTESY OF HOUSEKEEPING STAFF

 
 
 
 
 
 
 
 
 
 
 
 

018

CLEANLINESS OF ROOM

 
 
 
 
 
 
 
 
 
 
 
 

019

CLEANLINESS OF BATHROOM

 
 
 
 
 
 
 
 
 
 
 
 

020

ELIMINATION RATE OF ODORS

 
 
 
 
 
 
 
 
 
 
 
 

021

FACILITY CLEANLINESS

 
 
 
 
 
 
 
 
 
 
 
 

022

COURTESY OF LAUNDRY STAFF

 
 
 
 
 
 
 
 
 
 
 
 

023

QUALITY OF LAUNDRY SERVICE

 
 
 
 
 
 
 
 
 
 
 
 

024

TIMELINESS OF CLOTHING

 
 
 
 
 
 
 
 
 
 
 
 

025

LOSS OF PERSONAL ITEMS OR CLOTHING

 
 
 
 
 
 
 
 
 
 
 
 

026

COURTESY OF MAINTENANCE STAFF

 
 
 
 
 
 
 
 
 
 
 
 

027

SKILL LEVEL OF MAINTENANCE STAFF

 
 
 
 
 
 
 
 
 
 
 
 

028

RESPONSE TIME OF MAINTENANCE

 
 
 
 
 
 
 
 
 
 
 
 

029

FUNCTIONING OF APPLIANCES

 
 
 
 
 
 
 
 
 
 
 
 

030

FRIENDLINESS OF NURSING STAFF

 
 
 
 
 
 
 
 
 
 
 
 

031

PROFESSIONAL APPROACH OF NURSING STAFF

 
 
 
 
 
 
 
 
 
 
 
 

032

EXPLANATION OF CARE

 
 
 
 
 
 
 
 
 
 
 
 

033

TREATED WITH RESPECT & DIGNITY

 
 
 
 
 
 
 
 
 
 
 
 

034

TIMELINESSS OF PAIN MEDICATION

 
 
 
 
 
 
 
 
 
 
 
 

035

TIMELINESSS ROUTINE MEDICATION

 
 
 
 
 
 
 
 
 
 
 
 

036

NOISE LEVEL

 
 
 
 
 
 
 
 
 
 
 
 

037

DAY SHIFT NOISE LEVEL

 
 
 
 
 
 
 
 
 
 
 
 

038

AFTERNOON NOISE LEVEL

 
 
 
 
 
 
 
 
 
 
 
 

039

EVENING NOISE LEVEL

 
 
 
 
 
 
 
 
 
 
 
 

040

FRIENDLINESS OF NURSING ASSISTANTS STAFF

 
 
 
 
 
 
 
 
 
 
 
 

041

PROFESSIONAL APPROACH OF NURSING ASSISTANT STAFF

 
 
 
 
 
 
 
 
 
 
 
 

042

EXPLANATION OF CARE BY NURSING ASSISTANTS

 
 
 
 
 
 
 
 
 
 
 
 

043

CALL LIGHT RESPONSE TIME

 
 
 
 
 
 
 
 
 
 
 
 

044

TREATED WITH RESPECT & DIGNITY BY NURSING ASSISTANTS

 
 
 
 
 
 
 
 
 
 
 
 

045

DAY SHIFT CARE RECEIVED

 
 
 
 
 
 
 
 
 
 
 
 

046

AFTERNOON CARE RECEIVED

 
 
 
 
 
 
 
 
 
 
 
 

047

NIGHT SHIFT CARE RECEIVED

 
 
 
 
 
 
 
 
 
 
 
 

048

ASSISTING WITH DISCHARGE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

049

PROFESSIONAL APPROACH OF SOCIAL SERVICE STAFF

 
 
 
 
 
 
 
 
 
 
 
 

050

HOME CARE INFORMATION

 
 
 
 
 
 
 
 
 
 
 
 

051

EFFICIENCY OF DISCHARGE PROCESS

 
 
 
 
 
 
 
 
 
 
 
 

052

FRIENDLINESS OF THERAPIST

 
 
 
 
 
 
 
 
 
 
 
 

053

PROFESSIONAL APPROACH OF THERAPIST

 
 
 
 
 
 
 
 
 
 
 
 

054

TIMELINESS OF EVALUATION

 
 
 
 
 
 
 
 
 
 
 
 

055

EXPLANATION OF SERVICES

 
 
 
 
 
 
 
 
 
 
 
 

056

TREATED WITH RESPECT & DIGNITY BY THERAPIST

 
 
 
 
 
 
 
 
 
 
 
 
LTCSP SURVEY QUESTIONS - RESIDENT OBSERVATION

057

QIS

CLOTHING IN POOR REPAIR, IMPROPER FIT, OR WORN INAPPROPRIATELY

 
 
 
 
 
 
 
 
 
 
 
 

058

QIS

CLOTHING

 
 
 
 
 
 
 
 
 
 
 
 

059

QIS

FACIAL HAIR

 
 
 
 
 
 
 
 
 
 
 
 

060

QIS

FINGERNAILS

 
 
 
 
 
 
 
 
 
 
 
 

061

QIS

GLASSES

 
 
 
 
 
 
 
 
 
 
 
 

062

QIS

HAIR

 
 
 
 
 
 
 
 
 
 
 
 

063

QIS

MATTED EYES

 
 
 
 
 
 
 
 
 
 
 
 

064

QIS

MOUTH DEBRIS

 
 
 
 
 
 
 
 
 
 
 
 

065

QIS

SKIN UNCLEAN

 
 
 
 
 
 
 
 
 
 
 
 

066

QIS

UNPLEASANT BODY ODOR

 
 
 
 
 
 
 
 
 
 
 
 

067

QIS

CONTRACTURES - DOES THE RESIDENT HAVE A CONTRACTURE? (DEFINED AS A CONDITION OF FIXED HIGH RESISTANCE TO PASSIVE STRETCH OF A MUSCLE)

 
 
 
 
 
 
 
 
 
 
 
 

068

QIS

CONTRACTURES - DOES THE RESIDENT HAVE SPLINT DEVICES IN PLACE?

 
 
 
 
 
 
 
 
 
 
 
 

069

QIS

BED SIDE RAILS

 
 
 
 
 
 
 
 
 
 
 
 

070

QIS

CHAIR POTENTIALLY PREVENTS RISING

 
 
 
 
 
 
 
 
 
 
 
 

071

QIS

DOES THE RESIDENT HAVE A POTENTIAL RESTRAINT IN PLACE

 
 
 
 
 
 
 
 
 
 
 
 

072

QIS

POTENTIAL LIMB RESTRAINTS

 
 
 
 
 
 
 
 
 
 
 
 

073

QIS

POTENTIAL TRUNK RESTRAINT

 
 
 
 
 
 
 
 
 
 
 
 

074

QIS

IS THE DEVICE CORRECTLY APPLIED? (SUCH AS POTENTIAL TRUNK AND LIMB RESTRAINTS)

 
 
 
 
 
 
 
 
 
 
 
 

075

QIS

DID YOU OBSERVE THE RESIDENT IN ACTIVITIES

 
 
 
 
 
 
 
 
 
 
 
 

076

QIS

RESIDENT PARTICIPATION

 
 
 
 
 
 
 
 
 
 
 
 

077

QIS

PAIN - BODY LANGUAGE

 
 
 
 
 
 
 
 
 
 
 
 

078

QIS

PAIN - BREATHING

 
 
 
 
 
 
 
 
 
 
 
 

079

QIS

PAIN - FACIAL EXPRESSIONS

 
 
 
 
 
 
 
 
 
 
 
 

080

QIS

PAIN - MOVEMENT

 
 
 
 
 
 
 
 
 
 
 
 

081

QIS

PAIN - VOCALIZATION OF PAIN

 
 
 
 
 
 
 
 
 
 
 
 

082

QIS

ACCOMMODATION OF INDIVIDUAL NEEDS

 
 
 
 
 
 
 
 
 
 
 
 

083

QIS

PRIVACY

 
 
 
 
 
 
 
 
 
 
 
 

084

QIS

CLEAN BED/BATH LINENS

 
 
 
 
 
 
 
 
 
 
 
 

085

QIS

HYDRATION - PHYSICAL SIGNS OF DEHYDRATION

 
 
 
 
 
 
 
 
 
 
 
 

086

QIS

ABUSE - RESIDENT ABUSE

 
 
 
 
 
 
 
 
 
 
 
 

087

QIS

BROKEN TEETH

 
 
 
 
 
 
 
 
 
 
 
 

088

QIS

INFLAMED/ BLEEDING GUMS

 
 
 
 
 
 
 
 
 
 
 
 

089

QIS

LOOSE TEETH

 
 
 
 
 
 
 
 
 
 
 
 

090

QIS

MISSING TEETH

 
 
 
 
 
 
 
 
 
 
 
 

091

QIS

PROBLEMS WITH DENTURES

 
 
 
 
 
 
 
 
 
 
 
 

092

QIS

ACCIDENT HAZARDS - SIDE RAILS

 
 
 
 
 
 
 
 
 
 
 
 

093

QIS

ACCIDENT HAZARDS - SIDE RAILS PROPERLY FIT BED

 
 
 
 
 
 
 
 
 
 
 
 

094

QIS

ODOR IN ROOM

 
 
 
 
 
 
 
 
 
 
 
 

095

QIS

CLEANLINESS OF WALLS, FLOORS, CEILINGS, DRAPES, AND FURNITURE

 
 
 
 
 
 
 
 
 
 
 
 

096

QIS

POSITIONING - LACK OF HEAD OR TORSO SUPPORT

 
 
 
 
 
 
 
 
 
 
 
 

097

QIS

LIGHTING LEVELS

 
 
 
 
 
 
 
 
 
 
 
 

098

QIS

SOUND LEVEL

 
 
 
 
 
 
 
 
 
 
 
 

099

QIS

EVIDENCE OF INSECTS OR RODENTS

 
 
 
 
 
 
 
 
 
 
 
 

100

QIS

ELECTRIC CORDS, EXTENSION CORDS, OUTLETS SAFETY

 
 
 
 
 
 
 
 
 
 
 
 

101

QIS

AMBULATION, TRANSFER, OR THERAPY EQUIPMENT ARE UNCLEAN

 
 
 
 
 
 
 
 
 
 
 
 

102

QIS

SAFETY EQUIPMENT STATUS

 
 
 
 
 
 
 
 
 
 
 
 

103

QIS

CALL SYSTEM FUNCTIONING

 
 
 
 
 
 
 
 
 
 
 
 

104

QIS

SUFFICIENT STAFF - ENOUGH STAFF TO PROVIDE CARE AND ASSISTANCE WITHOUT A LONG WAIT

 
 
 
 
 
 
 
 
 
 
 
 

105

QIS

POSITIONING - BED SHEETS TUCKED TIGHTLY OVER TOES HOLDING THE FEET IN PLANTAR FLEXION

 
 
 
 
 
 
 
 
 
 
 
 

106

QIS

POSITIONING - DANGLING LEGS AND FEET

 
 
 
 
 
 
 
 
 
 
 
 

107

QIS

POSITIONING - LACK OF ARM OR SHOULDER SUPPORT

 
 
 
 
 
 
 
 
 
 
 
 

108

QIS

POSITIONING - LEANING TO THE SIDE WITHOUT SUPPORT

 
 
 
 
 
 
 
 
 
 
 
 

109

QIS

POSITIONING - MATTRESS SIZE

 
 
 
 
 
 
 
 
 
 
 
 

110

QIS

POSITIONING - PADDING BETWEEN BONY PROMINENCES

 
 
 
 
 
 
 
 
 
 
 
 

111

QIS

POSITIONING - OTHER POSITIONING CONCERNS

 
 
 
 
 
 
 
 
 
 
 
 

112

QIS

POSITIONING - SAGGING MATTRESS WHILE LAYING IN BED

 
 
 
 
 
 
 
 
 
 
 
 

113

QIS

POSITIONING - UNCOMFORTABLE GERI-CHAIR POSITIONING

 
 
 
 
 
 
 
 
 
 
 
 

114

QIS

POSITIONING - WHEELCHAIR SIZING

 
 
 
 
 
 
 
 
 
 
 
 

115

QIS

BED AND LINENS ARE VISIBLY SOILED WITH STOOL OR URINE

 
 
 
 
 
 
 
 
 
 
 
 

116

QIS

INCONTINENCE - SIGNS OF INCONTINENCE, SUCH AS ODOR AND/OR WETNESS

 
 
 
 
 
 
 
 
 
 
 
 

117

QIS

BRUISES

 
 
 
 
 
 
 
 
 
 
 
 

118

QIS

ABRASIONS AND / OR LACERATIONS

 
 
 
 
 
 
 
 
 
 
 
 

119

QIS

BURNS

 
 
 
 
 
 
 
 
 
 
 
 

120

QIS

SKIN TEARS

 
 
 
 
 
 
 
 
 
 
 
 

121

QIS

EXPLANATION OF SERVICE AND / OR CARE BY STAFF

 
 
 
 
 
 
 
 
 
 
 
 

122

QIS

FAILURE TO COVER A URINARY CATHETER BAG OR ANY OTHER TYPE OF BODY FLUID COLLECTION DEVICE

 
 
 
 
 
 
 
 
 
 
 
 

123

QIS

FAILURE TO RESPOND TO RESIDENT'S CALL LIGHTS FOR ASSISTANCE IN TIMLY MANNER

 
 
 
 
 
 
 
 
 
 
 
 

124

QIS

FAILURE TO TREAT RESIDENT RESPECTFULLY WHILE PROVIDING CARE TO RESIDENT OR ROOMMATE

 
 
 
 
 
 
 
 
 
 
 
 

125

QIS

VISIBILITY OF RESIDENT'S NAME ON CLOTHES

 
 
 
 
 
 
 
 
 
 
 
 

126

QIS

VISUAL PRIVACY OF RESIDENTS BODY IN PUBLIC AREAS

 
 
 
 
 
 
 
 
 
 
 
 

127

QIS

SEDATION - EXCESSIVELY SEDATED RESIDENTS

 
 
 
 
 
 
 
 
 
 
 
 

128

QIS

OTHER IDENTIFIED DIGNITY CONCERNS (DOCUMENT CONCERNS)

 
 
 
 
 
 
 
 
 
 
 
 

129

QIS

POSTING OF RESIDENT CONFIDENTIAL CLINICAL OR PERSONAL CARE INSTRUCTIONS IN VISIBLE AREAS

 
 
 
 
 
 
 
 
 
 
 
 

130

QIS

STAFF DRESSED RESIDENT IN INSTITUTIONALIZED FASHION DURING THE DAY

 
 
 
 
 
 
 
 
 
 
 
 

131

QIS

RESIDENT INCLUSION OF CONVERSATIONS WHILE PROVIDING CARE OR SERVICES

 
 
 
 
 
 
 
 
 
 
 
 

132

QIS

STAFF FAILED TO TREAT THE RESIDENT WITH RESPECT AND DIGNITY DURING CARE AND SERVICES

 
 
 
 
 
 
 
 
 
 
 
 

133

QIS

STAFF KNOCK / REQUEST PERMISSION TO ENTER RESIDENT'S ROOM

 
 
 
 
 
 
 
 
 
 
 
 

134

QIS

STAFF USAGE OF LABEL OF RESIDENT (I.E.,

 
 
 
 
 
 
 
 
 
 
 
 

135

QIS

CALL LIGHT NOT WITHIN REACH OF RESIDENT

 
 
 
 
 
 
 
 
 
 
 
 

136

QIS

ACCESSIBLE CHEMICALS OR OTHER HAZARDS IN BEDROOM OR BATHROOM

 
 
 
 
 
 
 
 
 
 
 
 

137

QIS

UNSAFE HOT WATER IN ROOM

 
 
 
 
 
 
 
 
 
 
 
 

138

QIS

HOT WATER IS TOO COOL

 
 
 
 
 
 
 
 
 
 
 
 

139

QIS

ROOM IS NOT HOMELIKE

 
 
 
 
 
 
 
 
 
 
 
 

140

QIS

POSITIONING - LONG PERIODS OF SAME POSITION

 
 
 
 
 
 
 
 
 
 
 
 

141

QIS

INAPPROPRIATE FOOT COVERINGS

 
 
 
 
 
 
 
 
 
 
 
 

142

QIS

INCONTINENCE - RESIDENT OBSERVATION FOR LONG PERIODS OF TIME WITHOUT BEING PROVIDED INCONTINENCE CARE

 
 
 
 
 
 
 
 
 
 
 
 

143

QIS

RESIDENT OBSERVED SMOKING DURING THE TWO DAYS OF STAGE 1

 
 
 
 
 
 
 
 
 
 
 
 

144

QIS

RESIDENT SMOKING SAFELY

 
 
 
 
 
 
 
 
 
 
 
 
LTCSP SURVEY QUESTIONS - RESIDENT INTERVIEW

145

QIS

ENCOURAGED BY STAFF TO BRING PERSONAL ITEMS

 
 
 
 
 
 
 
 
 
 
 
 

146

QIS

INFORM STAFF OF MISSING PERSONAL ITEMS

 
 
 
 
 
 
 
 
 
 
 
 

147

QIS

MISSING PERSONAL ITEMS

 
 
 
 
 
 
 
 
 
 
 
 

148

QIS

STAFF LOOKING FOR MISSING ITEMS

 
 
 
 
 
 
 
 
 
 
 
 

149

QIS

PERSONAL FUNDS - ACCESS TO PERSONAL FUNDS

 
 
 
 
 
 
 
 
 
 
 
 

150

QIS

PERSONAL FUNDS - KNOWLEDGE OF YOUR PERSONAL FUNDS

 
 
 
 
 
 
 
 
 
 
 
 

151

QIS

PERSONAL FUNDS - PERSONAL FUNDS ACCOUNT WITH FACILITY

 
 
 
 
 
 
 
 
 
 
 
 

152

QIS

BUILDING AND ENVIRONMENT - CLEANLINESS OF BUILDING

 
 
 
 
 
 
 
 
 
 
 
 

153

QIS

BUILDING AND ENVIRONMENT - PROBLEMS EFFECTING COMFORT

 
 
 
 
 
 
 
 
 
 
 
 

154

QIS

TELEPHONE

 
 
 
 
 
 
 
 
 
 
 
 

155

QIS

VISITOR AND RESIDENT PRIVACY

 
 
 
 
 
 
 
 
 
 
 
 

156

QIS

WHEN WORKING WITH RESIDENT

 
 
 
 
 
 
 
 
 
 
 
 

157

QIS

AVAILABILITY OF ACTIVITIES

 
 
 
 
 
 
 
 
 
 
 
 

158

QIS

ITEMS FOR INDIVIDUAL ACTIVITIES

 
 
 
 
 
 
 
 
 
 
 
 

159

QIS

MEET INTEREST OF RESIDENTS

 
 
 
 
 
 
 
 
 
 
 
 

160

QIS

PARTICIPATION IN ACTIVITY PROGRAMS

 
 
 
 
 
 
 
 
 
 
 
 

161

QIS

PARTICIPATION IN CARE PLAN - RESIDENT INCLUSION OF MEDICINE, THERAPY, AND OTHER TREATMENTS

 
 
 
 
 
 
 
 
 
 
 
 

162

QIS

RESIDENTS TREATED WITH RESPECT AND DIGNITY

 
 
 
 
 
 
 
 
 
 
 
 

163

QIS

ROOM TEMPERATURE

 
 
 
 
 
 
 
 
 
 
 
 

164

QIS

ABUSE - ABUSE TO RESIDENT

 
 
 
 
 
 
 
 
 
 
 
 

165

QIS

CHOICES - CHOOSE WHEN TO GO TO BED

 
 
 
 
 
 
 
 
 
 
 
 

166

QIS

CHOICES - VISITATION TIME

 
 
 
 
 
 
 
 
 
 
 
 

167

QIS

CHOICES - CHOOSE WHETHER TO TAKE SHOWER, TUB, OR BATH

 
 
 
 
 
 
 
 
 
 
 
 

168

QIS

CHOICES - CHOOSE WHEN TO GET UP IN THE MORNING

 
 
 
 
 
 
 
 
 
 
 
 

169

QIS

INTERACTION WITH OTHERS - CONCERNS OR PROBLEMS WITH A ROOMMATE OR OTHER RESIDENT

 
 
 
 
 
 
 
 
 
 
 
 

170

QIS

INTERACTION WITH OTHERS - STAFF ADDRESSING CONCERN(S)

 
 
 
 
 
 
 
 
 
 
 
 

171

QIS

NOTICE BEFORE ROOM CHANGE OR CHANGE IN ROOMMATE

 
 
 
 
 
 
 
 
 
 
 
 

172

QIS

MOVED TO DIFFERENT ROOM OR ROOMMATE CHANGE IN LAST NINE MONTHS

 
 
 
 
 
 
 
 
 
 
 
 

173

QIS

ABUSE - ABUSE BY STAFF, OTHER RESIDENTS, OR ANYONE ELSE

 
 
 
 
 
 
 
 
 
 
 
 

174

QIS

ABUSE - INFORMED STAFF OF ABUSE

 
 
 
 
 
 
 
 
 
 
 
 

175

QIS

ABUSE - OTHER RESIDENT ABUSE

 
 
 
 
 
 
 
 
 
 
 
 

176

QIS

PAIN - RESIDENT IN DISCOMFORT

 
 
 
 
 
 
 
 
 
 
 
 

177

QIS

ADL ASSISTANCE/URINARY INCONTINENCE - HELP NEEDED FOR GETTING DRESSED

 
 
 
 
 
 
 
 
 
 
 
 

178

QIS

ADL ASSISTANCE/URINARY INCONTINENCE - HELP NEEDED FOR ORAL CARE

 
 
 
 
 
 
 
 
 
 
 
 

179

QIS

DENTAL - PROBLEMS WITH TEETH, GUMS, OR DENTURES

 
 
 
 
 
 
 
 
 
 
 
 

180

QIS

DENTAL - STAFF SOLVING DENTAL PROBLEMS TO RESIDENT SATISFACTION

 
 
 
 
 
 
 
 
 
 
 
 

181

QIS

ADL ASSISTANCE/URINARY INCONTINENCE - HELP NEEDED FOR GOING TO BATHROOM

 
 
 
 
 
 
 
 
 
 
 
 
CoreQ QUESTIONS

182

COQ

CoreQ – Short-Stay Discharge - Question 1

 
 
 
 
 
 
 
 
 
 
 
 

183

COQ

CoreQ – Short-Stay Discharge - Question 2

 
 
 
 
 
 
 
 
 
 
 
 

184

COQ

CoreQ – Short-Stay Discharge - Question 3

 
 
 
 
 
 
 
 
 
 
 
 

185

COQ

CoreQ – Short-Stay Discharge - Question 4