Please select all that apply
Had to go to hospital due to poor care of nursing facility.Experienced broken bones while in the facility.Had a type 3 bedsore while in facility care.Experienced a bedsore at any stage while nursing facility.Wound care not properly treated and cared for.Family/Resident sexual harassed by staff and or residents.Have you been discriminated by a staff member.Do you feel a staff member shows racism or favoritism.Feel like you were retaliated by a staff member for complaining.Your issues, feelings and/or problems being ignored.Family/Resident harassed by staff and/or other resident/s.Family/Resident being neglected or ignored by staff.Felt as though you were belittled, laughed at and or moc ked.Do you feel your rights have been violated.Do you believe there are signs of over medicated residents at times.Medication given late or not on time periodically.Forced to move out of room.Staff not trained or gets rough when assisting in transfers.Physical therapy not given properly and/or not monitored.Had an incident (fall, soiled yourself, etc.) due to no help from staff.Unreasonable time for assistance when pulling call light.Not enough help staff-resident ratio.Rounds not being made.Call lights not in reach or working.Privacy violated, staff enters without knocking.Proper hygiene not given and/or available.Forced to wake up or go to bed.Being restricted from entering or leaving your room.Visitors restricted from visiting resident.Some staff being rude, lazy and very little help.Unable to find nurse or CNA in your area at times.Having been skipped or withheld of your medication.Skipped or withheld a food tray.Was given the wrong food tray.Meal was cold or too hot.Special diet meal not received.Snacks and hydration drinks not accessible or available.Missed your medical or personal appointments due to facility.Your well-being and/or medical necessities not being meet.Having lost or gained weight in short period of time.Not-all your necessities (oxygen, ted-hose, hot water, etc.) available.Unsanitary conditions in the facility (rest rooms, dining room, etc.).Beds rooms not clean and trash cans not emptied daily.Showers not given when wanting or needed and not accessible.Having issues with hot water.Resident’s oxygen tanks left emptyFacility not having needed equipment.Equipment not working properly.Staff not experienced with facilities equipment.Facility activities and/or smoking withheld.Environment not properly secured.Facility has bed bugs, roaches, ants, mice or other infestations.Maintenance not available and issues not fixed immediately.No access to phone, T.V., church, activities.Clothing or personals gone missing or stolen.Unreasonable costs for hair salon and/or facility amenities.Wheelchair and equipment not cleaned regular.Beds not made before you return to room from breakfast.Not having clean lining and towels available at all times.Laundry not properly done or returned.Having trouble getting or sending mail.Feel like you or your insurance is being charged for services not given.Not having access to a counselor, religious personal.Were you under duress, stressed (not thinking in a calm clear mind) when you signed agreement with this nursing facility.Are you stressed & nervous living in or dealing with this facility.Do you feel your life or loved one’s life could be in jeopardy.You do not feel this nursing facility has fulfilled their duties, obligations, and/or responsibilities with elderly care.Physical abused.Mentally abused.

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