Do you believe residents in your facility are experiencing some form of neglect or abuse?
Please selectYesNo

Are their signs or actions of severe abuse and neglect occurring in your facility?
Please selectYesNo

Is all the staff respected and treated fairly from management? If no what are those factors?

Do you feel all residents are treated fairly throughout your facility?
Please selectYesNo

Do you feel there is a high concern of residents daily charting not being properly done or falsely filled out? Due to any of the following issues no time, low staff, lazy staff, untrained, etc.?
Please selectYesNo

Is staff always trained, prepared, and informed of all resident’s issues, needs, and disabilities when taking on a new hall?
Please selectYesNo

Is the facility staff or yourself able to properly perform all daily job tasks thoroughly and safely?
Please selectYesNo

Have you or a coworker been a victim of abuse of any kind or civil rights violated while working for this facility?
Please selectYesNo

If yes to the previous question, what kind? Towards who and from whom?

Does staff answer the majority of residents call lights in a timely matter? 4-5 minutes? What is the average time in your facility?

Do you feel your facility is causing yourself or other staff to become highly stressed, causing body aches and mental anguish?
Please selectYesNo

Does your administrator and director of nurses assist and help when needed? Other than when state visits?
Please selectYesNo

Does administration attempt to correct or fix issues concerning residents or staff’s well-being?
Please selectYesNo

Are mandatory supplies and equipment always available?
Please selectYesNo

Is medication, food trays, showers, and therapy done or given approximately the same time daily?
Please selectYesNo

Is the majority of days or nights at your facility usually always short staffed?
Please selectYesNo

Today's Date

Your Name

Your Email or best contact info

Facility Name, City, State

Position