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* 2. Your Name and Relationship to the Resident (optional):

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* 3. Resident's Name (optional):

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* 4. How satisfied are you with the overall comfort of the home, including such factors as temperatures, noise, etc.?

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* 5. How satisfied are you with the overall cleanliness of the home?

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* 6. How satisfied are you with the safety and security in the home?

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* 7. How satisfied are you with the gentleness and respect shown by staff members when they are helping your family member?

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* 8. How satisfied are you with the facility’s efforts to accommodate individual resident needs and preferences?

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* 9. How satisfied are you with the accessibility of facility management?

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* 10. How satisfied are you with the communication from facility staff regarding your family member's care plan?

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* 11. How satisfied are you with the assistance provided by facility staff during the admission process and the first week of your family member's stay?

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* 12. Overall, how satisfied are you with the medical care provided by the staff (nursing and therapy)?

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* 13. Overall, how satisfied are you with the personal care provided by the staff (hygiene, grooming, activities, etc.)?

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* 14. Comments, Compliments & Suggestions:

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* 15. Did someone help you answer the questions in this survey?

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