Assisted Living Residence Survey Question Title * 1. Have you or a loved one resided in an Assisted Living Residence within the past several years? Yes No Question Title * 2. If yes, how long did he/she live in the Assisted Living Residence? 1-4 months 5-8 months 9 months to 1 year 1-2 years 2 years and longer Question Title * 3. How large was the Assisted Living Residence? Very small less than 10 beds Small 11-30 beds Medium 31-60 beds Large more than 60 beds Question Title * 4. How would you describe the care your loved one received in the Assisted Living Residence? Far above average Above average Average Below average Far below average Question Title * 5. Would you recommend this Assisted Living Facility to your friend/family? Yes, best care ever Yes, but it needs some changes No, didn't meet our needs/care No, worst care ever Question Title * 6. If the Assisted Living Residence needed some changes were they? Minor - more of a preference change Moderate - not harmful to our loved one, just an inconvenience Severe - issues that were not resolved Harmful to loved one and others No changes were needed. Question Title * 7. If changes were Moderate/Severe/Harmful which areas were impacted (select as many as you need) Staffing (includes training, manners, not enough staff, language barrier) Care provided (didn't meet care needs, didn't provide quality care, staff was not responsive, was rough or to fast) Facility (my health changed - ex: couldn't do stairs; facility was not clean, lack of privacy, too small or too big) Management (there were too many changes, didn't feel cared for, rules kept changing, didn't feel listen to, Safety (needed a memory care unit, felt threatened by staff/residents/management, staff was not responsive to needs, medication errors, mobility concerns) Personal (lack of autonomy, privacy issues, didn't like food, personal items disappeared, couldn't see family/friends) Other Question Title * 8. Would you be willing to send a short note about your good and bad experiences? Yes No Question Title * 9. If yes, please send to JLHENS@hotmail.com Question Title * 10. What is your age 18-30 31-40 41-50 51-60 61-70 71-80 81 and older Done