Bear Creek Room Inspection Audit

• Room Number

• Prepared by

• What is your initial impressions of cleanliness? (1 is terrible, 10 is Perfect)

• What is your initial impression of room condition? (1 is terrible, 10 is perfect)

• Swipe the screen to the left to continue with the audit.

Closet

• Is the closet frame broken or cracked?

  No

  Yes

• Are all the closet handles present and tight?

  Yes

  No

• Do the closet drawers work?

  Yes

  No

• Is the closet overloaded?

  Yes

  No

• Is there storage on the top shelf?

  No

  Yes

• Is the closet sprinkler head dirty? (Paint or Dust)

  No

  Yes

Sink area

• Is the counter cluttered?

  No

  Yes

• Is the counter clean?

  Yes

  No

• Are personal items all labeled?

  Yes

  No

• Are personal items all stored properly?

  Yes

  No

• Does the faucet leak or drip?

  No

  Yes

• Is the sink caulking in good condition?

  Yes

  No

• Is the sink cracked or chipped?

  No

  Yes

• Turn the hot water on to check for leaks. Leave it on to get hot, you will test the temperature later.

Under the sink

• Is the drain slow or does it leak?

  No

  Yes

• Is there anything stored under the sink?

  No

  Yes

• Is there a trashcan?

  Yes

  No

• Is the trash can fire resistant?

  Yes

  No

• Does the trashcan have extra lners?

  Yes

  No

• Is the trashcan full?

  No

  Yes

On the sink walls

• Are the toothbrush holders in good condition?

  Yes

  No

• Are there paper towels present?

  Yes

  No

• Is there soap in the dispenser?

  Yes

  No

• Are the towel hooks in good condition?

  Yes

  No

• Are there fresh towels?

  Yes

  No

• Is the mirror dirty?

  No

  Yes

• Does the mirror have chips, cracks, or paint?

  No

  Yes

• Is the sink light switch loose?

  No

  Yes

• Does the GFCI outlet reset?

  Yes

  No

• What is the lowest GFCI outlet tension measurment? (Requires special tool)

• Is the sink light switch loose?

  No

  Yes

• Are there any burned out bulbs in the sink light fixture?

  No

  Yes

• Is the sink light fixture in good condition?

  Yes

  No

Wall by bathroom door

• Is the coaxial outlet loose?

  No

  Yes

• Is the electrical outlet loose?

  No

  Yes

• Is the electrical outlet broken?

  No

  Yes

• What is the lowest outlet tension measurement? (Requires special tool)

Closet & Sink side wall condition

• Are the closet & sink side walls in good condition?

  Yes

  No

• Do these walls have unused nails?

  No

  Yes

• Are pins or tape being used on the sink side walls?

  No

  Yes

• Are there holes in the sink side walls?

  No

  Yes

• Do the sink side walls need paint?

  No

  Yes

• Add any pictures or information here to detailissues with the closet/sink areas.

• Swipe the screen left to move to the next section.

Bathroom door

• Does the bathroom door close and latch?

  Yes

  No

• Does the door open easily?

  Yes

  No

• Does the bathroom door stick on the frame or floor?

  No

  Yes

• Is the door knob loose?

  No

  Yes

• Does the door or the door frame require paint?

  No

  Yes

• Is the door or frame dusty or dirty?

  No

  Yes

Toilet

• Is the toilet dirty?

  No

  Yes

• Is the toilet loose?

  No

  Yes

• Is the toilet seat loose?

  No

  Yes

• Is the toilet leaking?

  No

  Yes

• Is the toilet stained around the pipe?

  Yes

  No

• Is the wall behind and below the toilet in good condition?

  Yes

  No

• Is the caulk around the toilet in good condition?

  Yes

  No

• Is the toilet cracked or chipped?

  No

  Yes

• Does the toilet have a weak flush?

  No

  Yes

• Is there an over-toilet seat?

  Yes

  No

• Is the over-toilet seat clean?

  Yes

  No

• Is there any tape or tape residue on the over-toilet chair?

  No

  Yes

• Are there any signs of rust or corrosion on the over-toilet chair?

  No

  Yes

Bathroom ceiling

• Is the bathroom light fixture cracked or broken?

  No

  Yes

• Does the bathroom light fixture have bugs or dust in it?

  Yes

  No

• Are the light bulbs working in the fixture?

  Yes

  No

• Is the bathroom fan too loud?

  No

  Yes

• Does the bathroom fan create enough suction? (Will it hold a square of toilet paper?)

  Yes

  No

• Is the bath fan dusty?

  No

  Yes

• Is the fire sprinkler dirty? (Paint or dust)

  No

  Yes

Convienence and mobility

• Is there excessive stuff stored above the toilet on the shelf?

  No

  Yes

• Are there any wipes or wipes packages in the bathroom?

  No

  Yes

• Is there a trashcan in the bathroom?

  Yes

  No

• Is the bathroom trash empty?

  Yes

  No

• Are there any grab bars in the bathroom?

  Yes

  No

• Are the grab bars solid and secure?

  Yes

  No

• Is there toilet paper in the holder?

  Yes

  No

Bathroom call station

• Does the bath call station have a plastic cord on it?

  Yes

  No

• Is the call station cord within 6" of the floor?

  No

  Yes

• When pulled, does the call station light come on?

  Yes

  No

• When pulled, do the light and alarm sound at the nurses station?

  Yes

  No

• When pulled, does the light come on in the corridor?

  Yes

  No

Bathroom walls

• Are the bathroom walls in good condition?

  Yes

  No

• Do the bathroom walls have any unused nails or screws?

  No

  Yes

• Are there holes in the bathroom walls?

  No

  Yes

• Are pins, tacks, or tape being used on the bathroom walls?

  No

  Yes

• Do the bathroom need to be painted?

  No

  Yes

• Is the bathroom baseboard in good condition?

  Yes

  No

• Is the baseboard heater bent?

  No

  Yes

• Is the bathroom baseboard heater missing panels or ends?

  No

  Yes

• Does the bathroom baseboard heater need paint?

  No

  Yes

Bathroom flooring

• Is the bathroom flooring sticky, disty, dirty, or mis-colored?

  No

  Yes

• Is the bathroom flooring peeling, cracked, or have holes in it?

  No

  Yes

• Add any additional information or pictures here.

• Add stuff here

• Swipe the screen to the left to continue with the audit.

Window

• Is the window clean?

  Yes

  No

• Is the window sill clean?

  Yes

  No

• Are the window tracks clean?

  Yes

  No

• Do both sides of the window open and close properly?

  Yes

  No

• Do both sides of the window latch closed?

  Yes

  No

• Are there 6" stoppers installed on both sides of the window?

  Yes

  No

• Does the weatherstripping appear in good condition?

  Yes

  No

Window coverings

• Are there drapes on the window?

  Yes

  No

• Are the drapes clean?

  Yes

  No

• Are the drapes frayed or torn?

  No

  Yes

• Are there a pull rod on both drapes?

  Yes

  No

• Are the drapes properly hung all the way accross the rod?

  Yes

  No

• Do the drapes have a label that states "NFPA 701"?

  Yes

  No

• Is the curtain rod secure?

  Yes

  No

• Does the window have blinds?

  Yes

  No

• Do the blinds work properly?

  Yes

  No

• Are the blinds clean?

  Yes

  No

Wall condition

• Is the window wall in good condition?

  Yes

  No

• Does the wall have unused nails or screws?

  No

  Yes

• Are pins, tacks, or tape being used on this wall?

  No

  Yes

• Does the window wall have holes in it?

  No

  Yes

• Does the window wall need paint?

  No

  Yes

Baseboard heater

• Is the baseboard heater bent?

  No

  Yes

• Is the baseboard heater missing panels?

  No

  Yes

• Does the baseboard heater need paint?

  No

  Yes

• Enter any additional information here.

• Swipe the screen to the left to continue the audit.

Wall finish condition

• Does the head wall have holes to be patched?

  No

  Yes

• Are pins, tacks, or tape being used on the wall?

  No

  Yes

• Does the wall have unused nails or screws?

  No

  Yes

• Does the head wall have paint on it?

  Yes

  No

• Does the wall need paint?

  No

  Yes

• Does the head wall have wallpaper on it?

  Yes

  No

• Is the wallpaper in good condition?

  Yes

  No

• Is the wallpaper peeling?

  No

  Yes

• Is the wallpaper torn?

  No

  Yes

Light fixture

• Is the light fixture in good condition?

  Yes

  No

• Are there items placed on top of the light fixture?

  No

  Yes

• Is the light fixture dirty?

  No

  Yes

• Does the "up light"work?

  Yes

  No

• Does the "down light" work?

  Yes

  No

• Is the light switch pull chain long enough?

  Yes

  No

• Is there any fabric based materials or tape on the light pull chain?

  No

  Yes

Low voltage

• Is the coaxial outlet in good condition?

  No

  Yes

• Is the coxial outlet loose?

  No

  Yes

• Is the telephone jack loose?

  No

  Yes

Electrical outlets on head wall

• Is the outlet(s) broken?

  No

  Yes

• Is the outlet loose?

  No

  Yes

• What is the lowest measured outlet tension?

Head wall call station

• Does the call station have a cord?

  Yes

  No

• Is the cord long enough?

  Yes

  No

• When pushed does the indicator light display?

  Yes

  No

• When pushed, does anindicator light and alarm sound at the nurses station?

  Yes

  No

• When pushed, does a visual indicator display in the corridor?

  Yes

  No

• Is there a clip on the cord? (Not a paper clip)

  Yes

  No

• Swipe the screen to the left to continue with the audit.

Light fixture

• Is the light fixture in good condition?

  Yes

  No

• Are there any items placed on the light fixture?

  Yes

  No

• Is the light fixture dirty?

  No

  Yes

• Is the fixture a full sized over-the-bed fixture?

  Yes

  No

• Does the down light work?

  Yes

  No

• Is the pull switch long enough?

  Yes

  No

• Does the pull switch have any fabric or strings attached to it?

  No

  Yes

• Are any lightbulbs burned out?

  No

  Yes

• Is the light switch "loose"?

  No

  Yes

Outlet

• Is the outlet broken?

  No

  Yes

• Is the outlet loose?

  No

  Yes

• What is the lowest measured outlet tension? (Requires special tool)

Wall finish condition

• Is the wall in good condition?

  Yes

  No

• Does the wall have unused nails or screws?

  No

  Yes

• Are pins, tacks, or tepe being used on the wall?

  No

  Yes

• Does the wall have holes to be patched?

  No

  Yes

• Does the wall need paint?

  No

  Yes

Nurse call station

• Is there a call station on the door wall?

  Yes

  No

• Does the call station have a call cord?

  Yes

  No

• Is the call cord long enough?

  Yes

  No

• When pushed does the indicator light up?

  Yes

  No

• When pushed, does the indicator and alarm sound at the nurses station?

  Yes

  No

• When pushed, does a indicator light up in the corridor?

  Yes

  No

Room door

• Does the room door close and latch?

  Yes

  No

• Does the door rub on the frame or floor?

  No

  Yes

• When closed, are there gaps larger than 1/4" around the top or sides of the door?

  No

  Yes

• Does the room door open easily?

  Yes

  No

• Is the door knob loose?

  No

  Yes

• Does the door or frame require paint?

  No

  Yes

• Is the door or frame dusty?

  No

  Yes

• Does anything prevent the door from closing? (Bed, air pump, etc..)

  No

  Yes

• Are any door stops present? (Trash can, rubber wedge, etc..)

  No

  Yes

• Is there a privacy curtain tie-back on the wall?

  Yes

  No

• Is the tie-back in good condition?

  Yes

  No

• Add any additional info here.

• Swipe the screen to the left tho cnotinue with the audit.

Ceiling

• Are there water stains on the ceiling?

  No

  Yes

• Is the ceiling texture "flaking" off the surface?

  No

  Yes

• Are there hooks or screws in the ceiling?

  No

  Yes

• Are there any holes in the ceiling?

  No

  Yes

• Does the ceiling need paint?

  No

  Yes

• Does the ceiling have any dust or cobwebs on it?

  No

  Yes

Privacy curtains

• Are the privacy curtain tracks tight to the ceiling?

  Yes

  No

• Are the privacy curtains clean?

  Yes

  No

• Are the privacy curtains torn?

  No

  Yes

• Do the privacy curtains extend long enough?

  Yes

  No

• Do the privacy curtains have the "NFPA 701" label?

  Yes

  No

Fire protection

• Are either of the sprinkler heads dirty? (Dust or paint)

  No

  Yes

• Do the sprinkler heads need to be caulked to the ceiling?

  No

  Yes

• Is the smoke detector dusty or dirty?

  No

  Yes

Flooring

• Is the floor dirty or sticky?

  No

  Yes

• Is the floor dirty under the beds?

  No

  Yes

• Is the floor waxed?

  Yes

  No

• Is the floor cracked or peeling up?

  No

  Yes

• Is there a threshold at the door?

  Yes

  No

• Is the threshhold in good condition?

  Yes

  No

• Are there any skid strips in the room?

  Yes

  No

• Are the skid strips in good condition?

  Yes

  No

• Add any additional information here.

• Swipe the screen to the left to continue with the audit.

Additional HVAC items

• Is there a window air conditoner unit in this room?

  Yes

  No

• Is the window AC unit in good condition?

  Yes

  No

• Is the AC unit air fliter clean?

  Yes

  No

• Does the AC side work?

  Yes

  No

• Does the heat side work?

  Yes

  No

• Is there an electric wall heater in this room?

  Yes

  No

• Does the wall heater work?

  Yes

  No

• Is there a through-wall PTAC unit in this room?

  Yes

  No

• Is the PTAC filter clean?

  Yes

  No

• Does the PTAC unit work?

  Yes

  No

• Enter any additional information here.

• Swipe the screen to the left to continue with the audit.

Environment

• Is the room or area too noisy

  No

  Yes

• Are there any unpleasant odors?

  No

  Yes

• Are there any signs of insects?

  No

  Yes

• Please explain where and details.

• What is the hot water temp?

• What is the room temp?

• Is there a thermostat in the room?

  Yes

  No

• What is the thermostat set at?

• What temp. Is the thermostat reading?

• Is there any hand sanitizer stored in the room?

  No

  Yes

• Are there any chemicals stored in the room? (More than 1 gallon total)

  No

  Yes

• Is there any storage within 18" of the ceiling?

  No

  Yes

Oxygen

• Is oxygen used by the residents of this room?

  Yes

  No

• Is there a "no smoking" sign on the outside of the door frame?

  Yes

  No

• Is the portable tank full?

  Yes

  No

• Does the oxygen tubing touch the floor?

  No

  Yes

• Enter any additional information here.

• Swipe the screen to the left to continue with the audit.

• Is there a bed on the A side of the room (or in the room if it's a private room)

  Yes

  No

Bed on the A side

• Is the bed made?

  Yes

  No

• Is there a "cleaned by..." label on the bed?

  Yes

  No

• Is the head board present and securely installed?

  Yes

  No

• Is the foot board present and securely installed?

  Yes

  No

• Is the mattress in good shape? (Firm and no cracks or tears)

  Yes

  No

• Is the bed positioned at a confortable low height?

  Yes

  No

• Is the bed positioned too close to the wall, outlet, or heat register? (Will it cause damage when it goes up/down)

  Yes

  No

• Do the controls work on the bed? (Manual or electric)

  Yes

  No

• Is the bed an electric high/low bed?

  Yes

  No

• Is the bed plug in good condition?

  Yes

  No

• Is the bed plugged directly into the wall?

  Yes

  No

• Is there a bed on the B side of the room (no if this is a private room)

  Yes

  No

Bed on the B side

• Is the bed made?

  Yes

  No

• Is there a "cleaned by..." label on the bed?

  Yes

  No

• Is the head board present and securely installed?

  Yes

  No

• Is the foot board present and securely installed?

  Yes

  No

• Is the mattress in good shape? (Firm and no cracks or tears)

  Yes

  No

• Is the bed positioned at a confortable low height?

  Yes

  No

• Is the bed positioned too close to the wall, outlet, or heat register? (Will it cause damage when it goes up/down)

  Yes

  No

• Do the controls work on the bed? (Manual or electric)

  Yes

  No

• Is the bed an electric high/low bed?

  Yes

  No

• Is the bed plug in good condition?

  Yes

  No

• Is the bed plugged directly into the wall?

  Yes

  No

• Enter any details here

• Swipe screen to the left to continue with audit.

Furnishings on the A side (or room)

Dresser

• Is there a dresser?

  Yes

  No

• Do the dresser drawers move smoothly?

  Yes

  No

• Are the dresses drawers secure?

  Yes

  No

Other furniture

• Is there a chair?

  Yes

  No

• Is the fabric on the chair in good condition and clean?

  Yes

  No

• Is there an over-bed table?

  Yes

  No

• Is there any unused furniture?

  No

  Yes

Wheelchair

• Is there a wheelchair?

  Yes

  No

• Is the wheelchair dirty?

  No

  Yes

• Are the arms or back of the wheelchair cracked or loose?

  No

  Yes

• Are the wheelchair brakes loose?

  No

  Yes

• Is this a private room?

  Yes

  No

Dresser on B side

• Is there a dresser?

  Yes

  No

• Are the dresses drawers secure?

  Yes

  No

• Do the dresser drawers move smoothly?

  Yes

  No

Other furniture on B side

• Is there any unused furniture?

  No

  Yes

• Is there an over-bed table?

  Yes

  No

• Is there a chair?

  Yes

  No

• Is the fabric on the chair in good condition and clean?

  Yes

  No

Wheelchair on B side

• Is there a wheelchair?

  Yes

  No

• Is the wheelchair dirty?

  No

  Yes

• Are the arms or back of the wheelchair cracked or loose?

  No

  Yes

• Are the wheelchair brakes loose?

  No

  Yes

• Describe any issues with the furniture.

• Swipe screen to the left to continue with audit.

• Is the A side of the room occupied? (If private, is the room occupied?)

  Yes

  No

Electronics on the A side

• Is there a television?

  Yes

  No

• Is there a remote for the television?

  Yes

  No

• Does the television/remote work?

  Yes

  No

• Is the TV safely located/mounted?

  Yes

  No

• Is there a telephone?

  Yes

  No

• Is the telephone located within reach of the resident?

  Yes

  No

• Is there a refrigerator?

  Yes

  No

• Does the fridge have a current temp log?

  Yes

  No

• Is there a thermometer in the fridge?

  Yes

  No

• Is there any open/undated food in the fridge?

  No

  Yes

• Is any of the food in the fridge past date?

  No

  Yes

• Is the fridge plugged directly into the wall?

  Yes

  No

• Are there any heating elements? (Heating pad, blow dryer, candle warmer)

  No

  Yes

• Are all medical devices plugged directly into the wall?

  Yes

  No

• Are any surge protectors used?

  Yes

  No

• Are only sensitive electronics plugged into the surge protectors?

  Yes

  No

• Are any extension cords or plug splitters used?

  No

  Yes

• Are all plugs and cords in good condition?

  Yes

  No

• Are any plugs missing the ground prong?

  No

  Yes

• Is the B side of the room occupied? ("No" if the room is private)

  Yes

  No

Electronics on the A side

• Is there a television?

  Yes

  No

• Is there a remote for the television?

  Yes

  No

• Does the television/remote work?

  Yes

  No

• Is the TV safely located/mounted?

  Yes

  No

• Is there a telephone?

  Yes

  No

• Is the telephone located within reach of the resident?

  Yes

  No

• Is there a refrigerator?

  Yes

  No

• Does the fridge have a current temp log?

  Yes

  No

• Is there a thermometer in the fridge?

  Yes

  No

• Is there any open/undated food in the fridge?

  No

  Yes

• Is any of the food in the fridge past date?

  No

  Yes

• Is the fridge plugged directly into the wall?

  Yes

  No

• Are there any heating elements? (Heating pad, blow dryer, candle warmer)

  No

  Yes

• Are all medical devices plugged directly into the wall?

  Yes

  No

• Are any surge protectors used?

  Yes

  No

• Are only sensitive electronics plugged into the surge protectors?

  Yes

  No

• Are any extension cords or plug splitters used?

  No

  Yes

• Are all plugs and cords in good condition?

  Yes

  No

• Are any plugs missing the ground prong?

  No

  Yes

• Add any details here.

• Swipe the screen to the left to continue with the audit.

Personal items on the A side. (Or in the eintire room if this is a private room)

• Is the A side occupied?

  Yes

  No

• Is there a fall pad?

  Yes

  No

• Is the fall pad clean?

  Yes

  No

• Does the fall pad have any rips or worn out edges?

  No

  Yes

• Are there any old dietary trays?

  No

  Yes

• Is there any open food?

  No

  Yes

• Is there open food in the dresser drawers?

  No

  Yes

• Are there any medications sitting out or in the dresser?

  No

  Yes

• Are the residents' clothes properly labeled?

  Yes

  No

• Is there a bedpan or urinal present?

  Yes

  No

• Is the bedpan or urinal properly covered?

  Yes

  No

• Is the A side of the room vacant?

  Yes

  No

• Is there any equipment or furniture being stored here?

  No

  Yes

• Are there any personal items from the previous resident here?

  No

  Yes

• Are there personal items that belong to a staff member here?

  No

  Yes

• Is there anything in the closet?

  No

  Yes

• Is there any trash laying around?

  No

  Yes

• Is the trash can empty with a new liner?

  Yes

  No

Personal items on the B side of the room

• Is the B side occupied?

  Yes

  No

• Is there a fall pad?

  Yes

  No

• Is the fall pad clean?

  Yes

  No

• Does the fall pad have any rips or worn out edges?

  No

  Yes

• Are there any old dietary trays?

  No

  Yes

• Is there any open food?

  No

  Yes

• Is there open food in the dresser drawers?

  No

  Yes

• Are there any medications sitting out or in the dresser?

  No

  Yes

• Are the residents' clothes properly labeled?

  Yes

  No

• Is there a bedpan or urinal present?

  Yes

  No

• Is the bedpan or urinal properly covered?

  Yes

  No

• Is the B side of the room vacant?

  Yes

  No

• Is there any equipment or furniture being stored here?

  No

  Yes

• Are there any personal items from the previous resident here?

  No

  Yes

• Are there personal items that belong to a staff member here?

  No

  Yes

• Is there anything in the closet?

  No

  Yes

• Is there any trash laying around?

  No

  Yes

• Is the trash can empty with a new liner?

  Yes

  No

• Enthe additional details here.

• Swipe screen to the left to continue audit.

• Final impression of room clenliness?

• Final impression of room condition?

• Any final details that need to be explained?

• Name of auditor

  Sign