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* 1. Please indicate your overall satisfaction with Program and Therapy Services in the following areas

  1  Needs Improvement 2 3 Satisfactory 4  5  Excellent Not Observed
Spiritual and Religious programming i.e. Worship Service/Hymn sing
Evening / weekend Recreation programming
Overall satisfaction with Recreation and Leisure services
In house Hair Care services
In house Physiotherapy services
I am aware of / have access to the Resident Council, Food Committee and/or Family Council

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* 2. Please indicate your satisfaction with Maintenance Services in the following areas

  1  Needs Improvement 2 3 Satisfactory 4 5  Excellent Not Observed
Garden, lawn and grounds keeping
Maintenance requests are attended to promptly
Temperature of the Home

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* 3. Please indicate how well you feel staff listen to you?

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* 4. Please indicate your satisfaction with Food and Nutrition Services in the following areas

  1  Needs Improvement 2 3 Satisfactory 4 5  Excellent Not Observed
Temperature of food
Menu choice
Attractive meal presentation
Meal service schedule i.e. meal times
 In house Dietitian services
Visitor Meals i.e.quality/cost

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* 5. Please indicate your satisfaction with General / Administration Services in the following areas

  1  Needs improvement 2 3 Satisfactory 4 5  Excellent Not Observed
Efficiency in dealing with trust accounts and billing
Information about care and services is available
Dignity and privacy is respected
Noise level in the home
The "Resident Bill of Rights" are posted and honoured
Social Work services

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* 6. Would you recommend this Long Term Care Home to others?

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* 7. Please indicate your satisfaction with Housekeeping and Laundry Services in the following areas

  1  Needs Improvement 2 3 Satisfactory 4 5  Excellent Not Observed
Resident room cleanliness
General home cleanliness
Odour control
Laundered items are returned promptly
Overall satisfaction with laundry services

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* 8. Please indicate your satisfaction with Medical, Nursing and Personal Care sevices in the following areas

  1  Needs Improvement 2 3 Satisfactory 4 5  Excellent Not Observed
Assistance with personal care i.e. bathing / grooming
Washroom Assistance
Quality of continence products
Registered Nursing services i.e. dispensing of medication
Opportunity for involvement in care planning and decisions related to care
Overall, how would you rate Nursing and Personal Care services
Physician services, consultation and care
In house Foot Care services
In house Dental services
The following questions relate to a resident's experience in the home.  If you are unable to complete or unsure, please answer "Not Observed" or click "Done" to complete the survey.

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* 9. Do staff introduce themselves to you and explain their role?

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* 10. Do staff address you by your preferred name or do they use words like "honey", "dear" etc.?

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* 11. When interacting with you or giving care, do staff explain to you what is going to take place?

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* 12. Do you feel staff intentionally start with what matters most to you when delivering care?

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* 13. When you are asked questions or are given information is it explained in a manner that you can understand?

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* 14. Do staff allow you to be as independent as possible or do they assist you with tasks that you would like to do yourself?

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* 15. Please indicate what best describes the individual(s) completing this survey (optional)

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* 16. Name (optional)

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* 17. Contact information (optional)

Please return your paper copy survey to the business office when complete.  Your input is valued and we thank you for taking time to complete this survey.

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