Facility Name*

City*

State*

Name*

Position*

Year of employment*

Today's Date

Please select all that apply
Sexual harassment staff on staffSexual harassment resident on staffRacism - discriminationHarassment of staff on staff, staff on resident, resident on resident, resident on staffNot getting paid for overtime hoursWages being withheld or not givenHours being cut - overtime being taken awayStaff member being moved to work another area for the dayBeing misinformed about residents when working a new hallNot being told about resident or residents changes (communication gap)Staff member talking about other staff member or members personal affairsCertain staff not assisting other staff members in lifting or changing a residentHurt my back lifting a resident due to improper staffing or unbearable conditionsStaff member disappeared and could not be foundStaff being pressured or harassed to work days off or linger shiftsSaw employee using the same gloves going from room to roomSaw call lights not being answered in a timely mannerRounds not being made due to time constrictions or laziness of an employeeSaw staff member or members carrying a dirty brief or linen down hallwayRelief not showing up to work on timeMultiple number of call ins or tardiness by certain employeesSaw staff not washing their hands after dealing with a residentStaff member retaliating against residentResident retaliating against staffNot enough help staff-resident rationCertain staff members not doing their job dutiesNo linens, sheets, and or towelsResident was not changed or soaked through upon starting your shiftNoticed numerous residents with 1st, 2nd, or 3rd stage bedsoresSaw resident left in chair and not being checkedResident's not getting showers due to lack of staff or time-consuming responsibilitiesResident forced to get up or stay in bedResident or employees missing belongingsResident forced to move out of their roomResident seems withdrawn or depressedHave you noticed a high possibility of information on resident’s charts being falsifiedNoticed hygiene not being done or maintained on residents (nails, teeth, dentures, etc.)Resident or residents not having access to TV and or phoneSaw resident's not being invited to activitiesResident being forced to get up as early as 4:30 amNoticed resident’s beds not being made in a proper time frameMissing resident (in the building or the outside unit)Heard of resident falls or injuries not being reportedUnexplained bruises on residentHeard or noticed resident blocked from entering or exiting their roomResidents dropped or gained weight quicklyNursing using chemical restraints on residentsHad to pass out medicine when not in job descriptionHad to do another CNA’s jobIncidents not being reported from nursing to managementResident request being ignoredWas verbally abused or belittledHeard family members given false or inaccurate informationNoticed medication not given on time or not at allHeard resident was given wrong medicationsRan out of resident’s medication - wound care productsNo wet floor signs being used when neededBugs in facility -filthy environmentNo hand sanitizer or soap availableSnack or ice not being passed outNo Dietary Nurse when passing out food traysFood trays given to wrong residentStaff eating resident’s foodNoticed hall trays given out late or residents being skippedTrash cans not being emptied when starting your shiftFacility, wheel chairs, restrooms, kitchen, etc. not being cleaned properlyRestroom fixtures, beds, outlets, flooring, etc. not getting fixedProper equipment not available or not workingSidewalk outside not properly taken care of during bad weatherNo security cameras in parking lot's

Do you feel body aches, headaches, and or heartache due to work environment?
Please selectYesNo

Do you feel stressed or upset when working with unprofessional management or lazy staff members?
Please selectYesNo

Do you have stress or anxiety do to work environment?
Please selectYesNo

Do you find it very time consuming when charting on kiosks or touch pads?
Please selectYesNo

Do you get neck aches when charting on kiosks or touch pads in the hallways?
Please selectYesNo

Do you believe that State (Ombudsman, DADs) makes a difference in nursing facilities
Please selectYesNo

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