1.Please identify how your assisted living community measures resident and family satisfaction. Mark all that apply.

My InnerView

Different outside organization

Internal satisfaction survey

Do not currently measure satisfaction

2.Please identify how your assisted living community measures employee satisfaction. Mark all that apply.

My InnerView

Different outside organization

Internal satisfaction survey

Do not currently measure satisfaction

3.What was your the average census/occupancy rate for December 2010, rounded to the nearest whole percent?

96-100%

91-95%

85-90%

80-84%

Less than 80 %

4.Does your community have a resident council that meets at least quarterly and encourages resident participation?

Yes

No

5.Does your community leadership meet regularly with the leaders of the resident council?

Yes

No

6.Does your community have a family council that meets at least quarterly and encourages family participation?

Yes

No

7.Does your community leadership meet regularly with the leaders of the family council?

Yes

No

8.Does your community have a mission statement?

Yes

No

9.Is your staff trained on the mission statement?

Yes

No

10.Does your community have a vision statement?

Yes

No

11.Is your staff trained on the vision statement?

Yes

No

12.Do you have a strategic plan that incorporates these statements?

Yes

No

13.Does your strategic plan incorporate performance data collected by the community?

Yes

No

14.Is your staff trained on the goals of the strategic plan?

Yes

No

15.Does your community review incident reports for residents?

Yes

No

16.Do you monitor and track employee safety?

Yes

No

17.Does your community review incident reports for staff?

Yes

No

18.Does your community track incident reports for family members and/or volunteers?

Yes

No

19.Does your community have a safety committee?

Yes

No

20.If you answered "yes" to 18, does your safety committee meet at least quarterly to review incident reports and available data to identify trends and patterns of risk?

Yes

No

Not applicable

21.If you answered "yes" to 19, do you conduct staff training as a result of that analysis?

Yes

No

Not applicable

22.Do you have a licensed nurse available to the staff and residents 24 hours a day?

Yes

No

23.If you answered "yes" to 21, please indicate how the licensed nurse is made available. Please mark all that apply.

On-site

Pager

Beeper

Telephone

Not applicable

24.Does your community conduct criminal background checks on all new employees?

Yes

No

25.What is the size of your community?

0-25 beds

26-50 beds

51-100 beds

>100 beds

*26.Please enter your community's name and address below.(Vereist.)

Community: *

Address:

Address 2:

City/Town:

State: *

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

ZIP/Postal Code:

27.Person completing survey:

Name:

Email Address:

Phone Number: