Nursing Home Performance Evaluation Form

Please rate each aspect on a scale from 1 to 5, with 1 representing the lowest rating and 5 representing the highest rating. Assign a score based on the performance observed or experienced, considering the quality, effectiveness, and satisfaction level. Aim to provide an accurate assessment that reflects the performance of the nursing home across various categories.

Facility Information

Nursing Home Name:	[Your Company Name]
Location:	[Your Company Address]
Date of Evaluation:	[Evaluation Date]
Evaluator(s):	[Evaluator's Name]

1. Staffing:

Aspect	Rating (1-5)	Comments
Adequacy of nursing staff (RN, LPN, CNA, etc.)	4	Sufficient staff present during evaluation.
Competency and training of staff
Staffing levels during day and night shifts
Communication and collaboration among staff

2. Resident Care:

Aspect	Rating (1-5)	Comments
Quality of medical care	4	Residents received prompt and appropriate medical attention.
Assistance with activities of daily living (ADLs)
Medication management
Responsiveness to resident needs
Social and recreational activities

3. Facility Environment:

Aspect	Rating (1-5)	Comments
Cleanliness and hygiene	5	Facility was clean and well-maintained throughout.
Maintenance of building and grounds
Safety features (e.g., handrails, call bells)
Accessibility for residents with mobility issues

4. Regulatory Compliance:

Aspect	Yes/No	Comments
Compliance with state regulations	Yes	No major violations observed during evaluation.
Compliance with federal regulations
Accreditation status (if applicable)

5. Communication:

Aspect	Rating (1-5)	Comments
Communication between staff and residents	4	Staff were communicative and respectful towards residents.
Communication between staff members
Communication with families/guardians

6. Quality Improvement:

Identify areas for improvement and develop action plans:

Area for improvement: Improve medication management procedures to ensure accuracy and completeness.
Action Plan: Implement regular audits of medication administration records.
Responsible Person(s): Nursing Supervisor, Pharmacy Coordinator

7. Overall Evaluation:

Write the overall evaluation and summarize the strengths and areas for improvement:

Overall Rating (1-5): 4

Summary of Strengths:

Effective communication, quality resident care, cleanliness, and safety.

Summary of Areas for Improvement:

Medication management procedures, communication with families, and enhancing recreational activities.

Evaluator:

[Evaluator's Name]

[Date]