Please complete this short survey on your nursing facility’s most recent DPH Annual Survey. Your feedback is important to our efforts to ensure statewide consistency in the survey process. All facility specific information will be kept confidential and information is shared with DPH in the aggregate.

This survey should only take a few minutes of your time. Any questions marked with an asterisk (*) requires an answer in order to progress through the survey. If you have any questions, please contact Helen Magliozzi, Director of Regulatory Affairs at 617.558.0202, ext.228 or e-mail her at hmagliozzi@maseniorcare.org.

* 1. Facility Name: (Optional)

* 2. Contact Person: (Optional)

* 3. Survey Region:

* 4. Survey Time Period:

Survey Start Date
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Survey End Date
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* 5. Total Number of Deficiencies:

* 6. Number of Deficiencies With:

* 7. List the names of the survey team members:

* 8. Please rate the following questions.

  5 = Strongly Agree 4 = Somewhat Agree 3 = Neither Agree nor Disagree 2 =  Somewhat Disagree 1 = Strongly Disagree
Surveyors exhibited appropriate knowledge of pertinent laws, regulations, guidelines, etc., during interactions with staff.
Surveyors showed respect towards staff. 
Surveyors showed respect for all residents, families and visitors. 
Surveyors participated in an ongoing dialogue with facility staff during the course of the survey. 
Surveyors provided staff with opportunities to discuss findings and provide explanations and/or supporting documentation prior to the exit conference. 

* 9. Please feel free to provide additional comments.

Thank you for your feedback! If you have any questions, please contact Helen Magliozzi, Director of Regulatory Affairs at Mass Senior Care.

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