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* 1. Do you or your family member reside in MKK-A, MKK-B or Kotitalo?

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* 2. Are you a resident or a family member?

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* 3. If you are a family member, are you the POA?

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* 4. If yes, please enter your e-mail address if appropriate.

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* 5. Regarding the nursing and personal care you or your family member receive at OFRA, on a scale of 1 to 5, where 1 is Strongly Disagree and 5 is Strongly Agree, please rate the following.  If "not applicable" please leave blank.

  1 2 3 4 5
I (or my family member) receive excellent care from the care staff.
Staff are respectful and courteous when communicating with me.
Staff ensures privacy during care.
Staff respond quickly to stated needs.
I (or my family member) feel safe and secure living at OFRA.
I (or my family member) am able to find a private place to visit with family and friends.
The doctor/nurse practitioner is available when needed for discussions.
The nursing staff is available when needed for discussions.
I (or my family member) receive my pain medication promptly after requesting it.
I (or my family member) am comfortable bringing my concerns to a staff member.
Bath and/or shower time is relaxed and un-rushed.
I can see that staff enjoy taking care of me (or my family member).
The home is kept at a comfortable temperature.
Staff allow me (or my family member) to make choices about my care.

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* 6. Regarding the activities and other engagements available to you or your family member, please rate the following:

  1 2 3 4 5
There are enough groups that provide physical activity.
There are enough activities offered outside.
There are enough groups that provide social interaction.
There are enough groups that support spiritual needs.
There are enough groups that provide cognitive (mental) stimulation.
There is enough variety of events offered.
There are enough events in the evening.
Spending time off of OFRA premises is beneficial.
There are enough events on the weekends.
Educational courses (such as computer skills, hearing aids, diabetes, dance lessons etc) helps with day-to-day activities.
You (or your family member) participate frequently in offered activities.
You (or your family member) feel there are too many activities planned at OFRA.

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* 7. With regard to food and meals, please rate the following.  If "not applicable" please leave blank.

  1 2 3 4 5
Meals start on time.
The server always uses sample plates.
I (or your family member) am asked which menu choice I would like from the available selections
Staff ensure that I (or your family member) get a preferred meal.
Food is served one table at a time, regardless of the menu choices of the table.
I (or your family member) always receive the correct diet type and texture.
The cereal/soup bowls are cleared before the entree is served.
The entree plates are cleared before dessert is served.
There is sufficient time allotted for me (or your family member) to eat at own pace.
Assistance is provided to me when I (or your family member) need it.
Staff offer second servings of meal items and beverages.
Beverages are being offered throughout the course of the meal.
Staff offer alternatives if you (or your family member) don't like/want what you've been served.
Dirty dishes are cleared from the table and scraped at the bussing cart.
The table set up looks appealing at meal time.
Staff interact with you (or your family member) and other residents throughout the meal and are not talking amongst themselves.
Food is offered separately and not mixed together for feeding (unless requested or stated in care plan).
My adaptive meal aides are at my place setting (as per care plan).
The Personal Support Workers or Dietary Aides use hand sanitizer during meal service.
The meal service is orderly.

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* 8. With regard to how clean you feel OFRA surroundings are, please rate the following.  If "not applicable" please leave blank.

  1 2 3 4 5
The overall building is clean.
The bedroom is kept clean.
The bathroom is kept clean.
There are enough linens, towels, etc.
Personal clothes are well laundered and returned in a timely manner.
The outside grounds are kept neat/clean.
The public washrooms are kept clean.
Hallways are mostly odour free.
The building is well maintained.

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* 9. Additional concerns not addressed above:

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* 10. Other comments?

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