CareGuard

Quality Report
How did we do?
Your Name
Phone Number
Email Address
example@example.com
Providing your contact information is optional, but it allows us to follow up on the incident if necessary.
Relationship to Resident or Facility Visitor*

VisitorFamily MemberStaff/WorkerOther
Facility Name
Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Incident

MonthDayYear
Date
Time of Incident
Was this incident observed by you personally?

YesNo
Location of incident

Resident RoomCommon AreaDining AreaHallwayRestroomOutdoorsOther
Category for Quality Improvement:
Health & Safety Concerns

Infection Control (e.g., signs of urinary or respiratory infections)Unattended Wounds, Cuts, or ScrapesBruising or Ecchymosis without ExplanationFall or Balance-Related IssuesImproper Handling of Medical EquipmentMedication Mismanagement (e.g., overmedication, missing doses)Other
Abuse or Mistreatment

Suspected Physical AbuseSuspected Emotional or Verbal AbuseNeglect of Resident’s Basic NeedsUnreasonable Use of Restraints (Physical or Chemical)Other
Hygiene & Cleanliness

Unsanitary Conditions (e.g., unclean rooms, soiled linens)Poor Personal Hygiene (e.g., residents not cleaned properly)Food Safety or Quality ConcernsOther
Staff Behavior

Inappropriate Staff ConductLack of Training or KnowledgeUnresponsiveness to Resident NeedsUnderstaffing or Overworked StaffOther
Resident Rights and Dignity

Lack of Respect for Resident’s Privacy or DignityIgnoring Resident's Complaints or RequestsUse of Degrading Language or BehaviorOther
Environmental Concerns

Unsafe Physical Environment (e.g., hazards, poor lighting)Heating, Cooling, or Ventilation ProblemsIssues with Accessibility (e.g., mobility barriers)Other
Compliance & Legal Concerns

Potential Regulatory ViolationsFinancial Abuse or ExploitationOther
Other Concerns:
Description about what happened, including who was involved, what was observed, and any other relevant information:
Was the incident reported to the Facility?*

YesNo
If the incident was reported to the Facility, what did the Facility do?
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By submitting this form, I confirm that the information provided is accurate to the best of my knowledge.
Would you like Follow-Up from CareGuard

YesNo
Signature

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Submit Date

MonthDayYear
Date
Hour Minutes
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