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1. Isabella Survey

1. Overall, how would you rate the services provided at the facility in the following areas:

	Excellent	Good	Average	Poor	Unacceptable	N/A
Security Services	*Overall, how would you rate the services provided at the facility in the following areas: Security Services Excellent	Security Services Good	Security Services Average	Security Services Poor	Security Services Unacceptable	Security Services N/A
Environmental Services	Environmental Services Excellent	Environmental Services Good	Environmental Services Average	Environmental Services Poor	Environmental Services Unacceptable	Environmental Services N/A
Nursing Assistant/Aide	Nursing Assistant/Aide Excellent	Nursing Assistant/Aide Good	Nursing Assistant/Aide Average	Nursing Assistant/Aide Poor	Nursing Assistant/Aide Unacceptable	Nursing Assistant/Aide N/A
Nursing Services	Nursing Services Excellent	Nursing Services Good	Nursing Services Average	Nursing Services Poor	Nursing Services Unacceptable	Nursing Services N/A
Food Services	Food Services Excellent	Food Services Good	Food Services Average	Food Services Poor	Food Services Unacceptable	Food Services N/A
Dietician Services	Dietician Services Excellent	Dietician Services Good	Dietician Services Average	Dietician Services Poor	Dietician Services Unacceptable	Dietician Services N/A
Physician Services	Physician Services Excellent	Physician Services Good	Physician Services Average	Physician Services Poor	Physician Services Unacceptable	Physician Services N/A
Social Services	Social Services Excellent	Social Services Good	Social Services Average	Social Services Poor	Social Services Unacceptable	Social Services N/A
Recreation Therapy	Recreation Therapy Excellent	Recreation Therapy Good	Recreation Therapy Average	Recreation Therapy Poor	Recreation Therapy Unacceptable	Recreation Therapy N/A
Admissions	Admissions Excellent	Admissions Good	Admissions Average	Admissions Poor	Admissions Unacceptable	Admissions N/A
Laundry Services (Clothing)	Laundry Services (Clothing) Excellent	Laundry Services (Clothing) Good	Laundry Services (Clothing) Average	Laundry Services (Clothing) Poor	Laundry Services (Clothing) Unacceptable	Laundry Services (Clothing) N/A
Reception(Security Desk)	Reception(Security Desk) Excellent	Reception(Security Desk) Good	Reception(Security Desk) Average	Reception(Security Desk) Poor	Reception(Security Desk) Unacceptable	Reception(Security Desk) N/A
Billing/Finance Services	Billing/Finance Services Excellent	Billing/Finance Services Good	Billing/Finance Services Average	Billing/Finance Services Poor	Billing/Finance Services Unacceptable	Billing/Finance Services N/A
Rehabilitation Services (If applicable)	Rehabilitation Services (If applicable) Excellent	Rehabilitation Services (If applicable) Good	Rehabilitation Services (If applicable) Average	Rehabilitation Services (If applicable) Poor	Rehabilitation Services (If applicable) Unacceptable	Rehabilitation Services (If applicable) N/A

2. Please rate the availability of the choices afforded in the following areas:

	Excellent	Good	Average	Poor	Unacceptable
Meal variety	*Please rate the availability of the choices afforded in the following areas: Meal variety Excellent	Meal variety Good	Meal variety Average	Meal variety Poor	Meal variety Unacceptable
Wake up time/Going to bed time	Wake up time/Going to bed time Excellent	Wake up time/Going to bed time Good	Wake up time/Going to bed time Average	Wake up time/Going to bed time Poor	Wake up time/Going to bed time Unacceptable
Time and frequency of bathing	Time and frequency of bathing Excellent	Time and frequency of bathing Good	Time and frequency of bathing Average	Time and frequency of bathing Poor	Time and frequency of bathing Unacceptable
Scheduling of time	Scheduling of time Excellent	Scheduling of time Good	Scheduling of time Average	Scheduling of time Poor	Scheduling of time Unacceptable

3. Overall, please rate your experiences with the following:

	Excellent	Good	Average	Poor	Unacceptable	N/A
You are familiar with staff members who care for you, your family member/friend?	*Overall, please rate your experiences with the following: You are familiar with staff members who care for you, your family member/friend? Excellent	You are familiar with staff members who care for you, your family member/friend? Good	You are familiar with staff members who care for you, your family member/friend? Average	You are familiar with staff members who care for you, your family member/friend? Poor	You are familiar with staff members who care for you, your family member/friend? Unacceptable	You are familiar with staff members who care for you, your family member/friend? N/A
Staff interacts appropriately with the resident?	Staff interacts appropriately with the resident? Excellent	Staff interacts appropriately with the resident? Good	Staff interacts appropriately with the resident? Average	Staff interacts appropriately with the resident? Poor	Staff interacts appropriately with the resident? Unacceptable	Staff interacts appropriately with the resident? N/A
You are kept apprised and informed about your, your family member's/friend's care?	You are kept apprised and informed about your, your family member's/friend's care? Excellent	You are kept apprised and informed about your, your family member's/friend's care? Good	You are kept apprised and informed about your, your family member's/friend's care? Average	You are kept apprised and informed about your, your family member's/friend's care? Poor	You are kept apprised and informed about your, your family member's/friend's care? Unacceptable	You are kept apprised and informed about your, your family member's/friend's care? N/A
You are kept up to date about changes in your health or the health of your family member/friend?	You are kept up to date about changes in your health or the health of your family member/friend? Excellent	You are kept up to date about changes in your health or the health of your family member/friend? Good	You are kept up to date about changes in your health or the health of your family member/friend? Average	You are kept up to date about changes in your health or the health of your family member/friend? Poor	You are kept up to date about changes in your health or the health of your family member/friend? Unacceptable	You are kept up to date about changes in your health or the health of your family member/friend? N/A
Your or your family member's/friend's health information is kept private and confidential?	Your or your family member's/friend's health information is kept private and confidential? Excellent	Your or your family member's/friend's health information is kept private and confidential? Good	Your or your family member's/friend's health information is kept private and confidential? Average	Your or your family member's/friend's health information is kept private and confidential? Poor	Your or your family member's/friend's health information is kept private and confidential? Unacceptable	Your or your family member's/friend's health information is kept private and confidential? N/A
Your or your family member/friend's belongings are free from loss or use by others?	Your or your family member/friend's belongings are free from loss or use by others? Excellent	Your or your family member/friend's belongings are free from loss or use by others? Good	Your or your family member/friend's belongings are free from loss or use by others? Average	Your or your family member/friend's belongings are free from loss or use by others? Poor	Your or your family member/friend's belongings are free from loss or use by others? Unacceptable	Your or your family member/friend's belongings are free from loss or use by others? N/A
The facility, as a whole, is clean and well maintained in its appearance?	The facility, as a whole, is clean and well maintained in its appearance? Excellent	The facility, as a whole, is clean and well maintained in its appearance? Good	The facility, as a whole, is clean and well maintained in its appearance? Average	The facility, as a whole, is clean and well maintained in its appearance? Poor	The facility, as a whole, is clean and well maintained in its appearance? Unacceptable	The facility, as a whole, is clean and well maintained in its appearance? N/A
The physical appearance and hygiene of the resident is maintained?	The physical appearance and hygiene of the resident is maintained? Excellent	The physical appearance and hygiene of the resident is maintained? Good	The physical appearance and hygiene of the resident is maintained? Average	The physical appearance and hygiene of the resident is maintained? Poor	The physical appearance and hygiene of the resident is maintained? Unacceptable	The physical appearance and hygiene of the resident is maintained? N/A
You have or your family member/friend has the choice to engage in activities and recreation?	You have or your family member/friend has the choice to engage in activities and recreation? Excellent	You have or your family member/friend has the choice to engage in activities and recreation? Good	You have or your family member/friend has the choice to engage in activities and recreation? Average	You have or your family member/friend has the choice to engage in activities and recreation? Poor	You have or your family member/friend has the choice to engage in activities and recreation? Unacceptable	You have or your family member/friend has the choice to engage in activities and recreation? N/A
Youe are or your family member/friend is treated with respect and able to maintain a sense of dignity?	Youe are or your family member/friend is treated with respect and able to maintain a sense of dignity? Excellent	Youe are or your family member/friend is treated with respect and able to maintain a sense of dignity? Good	Youe are or your family member/friend is treated with respect and able to maintain a sense of dignity? Average	Youe are or your family member/friend is treated with respect and able to maintain a sense of dignity? Poor	Youe are or your family member/friend is treated with respect and able to maintain a sense of dignity? Unacceptable	Youe are or your family member/friend is treated with respect and able to maintain a sense of dignity? N/A
A quiet, peaceful and private place is available to you, your family member/friend?	A quiet, peaceful and private place is available to you, your family member/friend? Excellent	A quiet, peaceful and private place is available to you, your family member/friend? Good	A quiet, peaceful and private place is available to you, your family member/friend? Average	A quiet, peaceful and private place is available to you, your family member/friend? Poor	A quiet, peaceful and private place is available to you, your family member/friend? Unacceptable	A quiet, peaceful and private place is available to you, your family member/friend? N/A
Your or your family member/friend's medication is well managed?	Your or your family member/friend's medication is well managed? Excellent	Your or your family member/friend's medication is well managed? Good	Your or your family member/friend's medication is well managed? Average	Your or your family member/friend's medication is well managed? Poor	Your or your family member/friend's medication is well managed? Unacceptable	Your or your family member/friend's medication is well managed? N/A
Your or your family member/friend's pain is managed and controlled?	Your or your family member/friend's pain is managed and controlled? Excellent	Your or your family member/friend's pain is managed and controlled? Good	Your or your family member/friend's pain is managed and controlled? Average	Your or your family member/friend's pain is managed and controlled? Poor	Your or your family member/friend's pain is managed and controlled? Unacceptable	Your or your family member/friend's pain is managed and controlled? N/A

Comments

4. Would you recommend this facility to a friend or other family member?

Would you recommend this facility to a friend or other family member? Yes

5. Overall, please rate your experience with the care you or your family member/friend receives.

Overall, please rate your experience with the care you or your family member/friend receives. Excellent

Good

Average

Poor

Unacceptable

6. Describe the resident's relationship to you:

Describe the resident's relationship to you: Spouse/Partner	Parent	Sibling	Friend	Grandparent	Resident (Self)
Other (please specify)

7. Is there anything else you would like to share with us?

Is there anything else you would like to share with us?

8. If you would like someone to contact you, please provide your contact information:

If you would like someone to contact you, please provide your contact information:

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