Bluestone - TJC

• Site conducted

  Select

• Conducted on

  Date

• Site name

• Prepared by

• Inspected by

• Location
  Address

Main Entry

• Entry doors are locked and in working condition?

  Yes

  No

  N/A

• Entry areas are clean and in a safe condition?

  Yes

  No

  N/A

• Entry call buttons are in working order at time of inspection? Test during PRA.

  Yes

  No

  N/A

• Licensure and accreditation documents posted with current dates?

  Yes

  No

  N/A

• Occupancy posted?

  Yes

  No

  N/A

• Lobby areas are clean and free from safety concerns or issues?

  Yes

  No

  N/A

• Hallways leading to patient areas are clean and free from safety concerns or issues?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness issues related to entry and lobby areas?

  Yes

  No

  N/A

Cleaning Closet?

• Closet is locked upon inspection?

  Yes

  No

  N/A

• Closet is clean and free from excessive clutter?

  Yes

  No

  N/A

• SDS book is present, all chemicals present are found in SDS book at the time of inspection?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness issues?

  Yes

  No

  N/A

Exam Room

• Exam room is clean, safe and in good condition?

  Yes

  No

  N/A

• Furniture in the exam room is clean, safe and in good condition?

  Yes

  No

  N/A

• Items stored in the exam room are stored under safe conditions preventing risks to patients? All drawers and cabinets locked?

  Yes

  No

  N/A

• Medical equipment has been inspected, is properly tagged with inspection date, and date is not expired? Verify tags and note any issues.

  Yes

  No

  N/A

• Ceiling tiles and light fixtures are present and free from stains? If no, note where and put in a work order.

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness issues related to the exam room?

  Date

Seclusion and Restraint

• Seclusion room doors lock according to design?

  Yes

  No

  N/A

• Doors are in good condition and free from safety issues?

  Yes

  No

  N/A

• Rooms are safe and appropriate for seclusion and/or restraint?

  Yes

  No

  N/A

• Beds stored in S/R room are safe and in good condition?

  Yes

  No

  N/A

• The bathroom in the S/R area is clean?

  Yes

  No

  N/A

• The bathroom in S/R is safe?

  Yes

  No

  N/A

• Lighting in the S/R area is adequate and in working order?

  Yes

  No

  N/A

• Ceiling tiles and light fixtures are present and free from stains? If no, note where and put in a work order.

  Yes

  No

  N/A

• Temperature in the S/R is comfortable to season?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness issues related to S/R area?

  Yes

  No

  N/A

Clean Linen Room

• Items in clean linen room are at least 18 inches from the ceiling? Note, only a single layer allowed on the top shelf. If no, note what is being stored within 18 inches of the ceiling.

  Yes

  No

  N/A

• Clean linen room is orderly and free from excessive clutter? Nothing stored on the ground. If no, note what is there and where it's located.

  Yes

  No

  N/A

• Covers over the clean linen are zipped closed? If no, note which one was open and close it before leaving the room.

  Yes

  No

  N/A

• Water stored in the clean linen room is up-to-date? Note expiration date for each jug in comments.

  Yes

  No

  N/A

• Ceiling tiles and light fixtures are present and free from stains? If no, note where and put in a work order.

  Yes

  No

  N/A

• Any additional issues related to compliance, safety, security, or cleanliness?

  Yes

  No

  N/A

Dirty Linen Room

• Dirty linen room is orderly and free from excessive clutter? Nothing stored on the ground. If no, note what is there and where it's located.

  Yes

  No

  N/A

• Ceiling tiles and light fixtures are present and free from stains? If no, note where and put in a work order.

  Yes

  No

  N/A

• SDS book is present, all chemicals in room are found in the book? If no, note what is there that is not found in the book and remove it.

  Yes

  No

  N/A

• Hooks and glove holder are secure on the wall? If no, note what is loose and put in a work order.

  Yes

  No

  N/A

• Walls are clean and free from damage? If no, note where and put in a work order.

  Yes

  No

  N/A

• Any additional issues related to compliance, safety, security, or cleanliness?

  Yes

  No

  N/A

Secondary/Ambulance Entry

• Area is clean and egress is clear with noting stored in entryway? If no, note what is stored and put in work order for removal.

  Yes

  No

  N/A

• Area under the stairwell is clear with noting stored under stairs? Is no, note what is stored and put in work order for removal.

  Yes

  No

  N/A

• Walls are clean and free from damage? If no, note where and put in a work order.

  Yes

  No

  N/A

• Ceiling tiles and light fixtures are present and free from stains? If no, note where and put in a work order.

  Yes

  No

  N/A

• Any additional issues related to compliance, safety, security, or cleanliness?

  Yes

  No

  N/A

Nursing Station

• Area is free from excessive clutter? If no, note where and what the items are.

  Yes

  No

  N/A

• Crash cart is accessible and items stored are ordered and current? Verify expiration dates.

  Yes

  No

  N/A

• Entry and exits are clear at time of inspection? If no, note what is blocking area and where it's located.

  Yes

  No

  N/A

• Overall walls are clean and in good condition?

  Yes

  No

  N/A

• Fire Extinguisher has been checked routinely? If no, note what is missing.

  Yes

  No

  N/A

• Eye Wash Station is up-to-date? Note the expiration date on the water jugs.

  Yes

  No

  N/A

• Any additional issues related to compliance, safety, security, or cleanliness?

  Yes

  No

  N/A

Medication Room

• Area is free from excessive clutter? If no, note where and what the items are.

  Yes

  No

  N/A

• Required postings are present? High-Alert medications, look-alike-sound-alike medications lists.

  Yes

  No

  N/A

• Medications are stored properly? If no, note the issue and address immediately with nursing team.

  Yes

  No

  N/A

• Temperature log is present and current on fridge?

  Yes

  No

  N/A

• Fridge is free from ice build-up?

  Yes

  No

  N/A

• Medications and supplies are current and up-to-date? Verify expiration dates on medications stored in cupboards and supplies.

  Yes

  No

  N/A

• Any additional issues related to compliance, safety, security, or cleanliness?

  Yes

  No

  N/A

Common Areas, Patient Care

• Furniture in patient common areas is clean, safe and in good condition?

  Yes

  No

  N/A

• Common areas appear clean?

  Yes

  No

  N/A

• Common area is free from safety issues?

  Yes

  No

  N/A

• Common areas vents are free from dust and/or dust build-up?

  Yes

  No

  N/A

• Trash in common areas is contained?

  Yes

  No

  N/A

• Posting in common areas are present, including patient rights, meals, and daily schedule? There are cues to alert patients of date and time?

  Yes

  No

  N/A

• Temperature in client care areas is comfortable to season?

  Yes

  No

  N/A

• Sound reducing ceiling fixtures are free from damage?

  Yes

  No

  N/A

• Walls are free from damage? If no, put in a work order and note where.

  Yes

  No

  N/A

• Any additional issues related to compliance, safety, security, or cleanliness in common areas?

  Yes

  No

  N/A

Servery

• Servery is locked?

  Yes

  No

  N/A

• Servery is clean?

  Yes

  No

  N/A

• Are there boxed gloves available?

  Yes

  No

  N/A

• Is ice machine clean and free of mildew?

  Yes

  No

  N/A

• Refrigerator logs are present and completed to date?

  Yes

  No

  N/A

• On inspection, refrigerator is holding proper temperature?

  Yes

  No

  N/A

• Refrigerator is free from expired items? Verified by checking at least 5 different items from 5 different locations within the fridge, front and back of the fridge.

  Yes

  No

  N/A

• Food stored in servery is being stored at proper temperature and condition? Anything on the counter must be covered and dated with a time. Anything in the fridge must be covered and have a date or expiration date.

  Yes

  No

  N/A

• Area under the sink is free of client care items? If no, note what is stored under the sink.

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness concerns?

  Yes

  No

  N/A

Laundry

• Laundry Room is locked at time of inspection?

  Yes

  No

  N/A

• Lint trap is free of excessive lint?

  Yes

  No

  N/A

• Clothes and client items are stored properly with nothing found on the floor?

  Yes

  No

  N/A

• Items are stored properly and are not within 18 inches of the ceiling?

  Yes

  No

  N/A

• SDS book is present, all chemicals present are found in SDS book at the time of inspection?

  Yes

  No

  N/A

• There are no items being stored on top of the ice machine or in the laundry room that do not belong? If items are present, note the location and what the item is.

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness concerns related to laundry room?

  Yes

  No

  N/A
Group Rooms

• Group room number

• Group room is clean?

  Yes

  No

  N/A

• Group room is free from safety issues?

  Yes

  No

  N/A

• Furniture in group room is clean, safe and in good condition?

  Yes

  No

  N/A

• Group room vents are free from dust and/or dust build-up?

  Yes

  No

  N/A

• Sound reducing ceiling fixtures are free from damage?

  Yes

  No

  N/A

• Walls are free from damage? If no, put in a work order and note where.

  Yes

  No

  N/A

• Any additional issues related to compliance, safety, security, or cleanliness in group room?

  Yes

  No

  N/A
Patient Rooms

• Room Number

• Furniture is in good condition and is safe for patient use?

  Yes

  No

  N/A

• Overall the room is clean?

  Yes

  No

  N/A

• Overall the room is safe for patient care?

  Yes

  No

  N/A

• Doors and light fixtures are safe and in working order?

  Yes

  No

  N/A

• Temperature in patient rooms is comfortable to season?

  Yes

  No

  N/A

• Bathroom in patient room is safe and in good condition?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness concerns related to patient room?

  Yes

  No

  N/A
Common Bathrooms

• Room number of bathroom

• Bathrooms are clean?

  Yes

  No

  N/A

• Bathrooms are safe?

  Yes

  No

  N/A

• Trash in bathroom areas is contained?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness concerns related to bathroom area?

  Yes

  No

  N/A
Patient Outdoor Areas

• Identify Wing

• Area is free from safety issues?

  Yes

  No

  N/A

• Free from holes/hives/nests or other damage related to pests?

  Yes

  No

  N/A

• Exterior is in good condition?

  Yes

  No

  N/A

• Entry ways are free from tripping hazards and maintained according to season?

  Yes

  No

  N/A

• Fences/retaining walls are in good condition?

  Yes

  No

  N/A

• Gutters and downspouts are in good condition?

  Yes

  No

  N/A

• Locks present and in good condition?

  Yes

  No

  N/A

• Any additional issues related to compliance, safety, security, or cleanliness?

  Yes

  No

  N/A

Consult Room

• Furniture is in good condition and is safe for patient use?

  Yes

  No

  N/A

• Overall the room is clean and free from clutter?

  Yes

  No

  N/A

• Overall the room is safe for patient care?

  Yes

  No

  N/A

• Doors and light fixtures are safe and in working order?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness concerns related to consult room?

  Yes

  No

  N/A

Utility and Storage Areas

• Items in storage areas are not stored within 18 inches of the ceiling?

  Yes

  No

  N/A

• Storage areas are orderly and free from excessive clutter?

  Yes

  No

  N/A

• Utility Rooms are labeled with shut-offs?

  Yes

  No

  N/A

• Areas storing hazardous waste is marked?

  Yes

  No

  N/A

• Hazardous waste is stored under proper condition?

  Yes

  No

  N/A

Additional Areas

• Areas deemed as "secure" are locked upon inspection? (Examples: Medication closets, bathrooms, utility closets, janitor closets, etc.)

  Yes

  No

  N/A

• Ceiling tiles and light fixtures are present and free from stains?

  Yes

  No

  N/A

• Flooring is in good condition and free from trip hazards?

  Yes

  No

  N/A

• Overall walls are clean and in good condition?

  Yes

  No

  N/A

• All entries and exits are clear at time of inspection? If no, note what is blocking area and where it's located.

  Yes

  No

  N/A

• Exit signs are in working order?

  Yes

  No

  N/A

• Fire extinguishers are labeled and have monthly inspection?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness issues related to the general areas?

  Yes

  No

  N/A

• Sidewalks leading to the building are safe and in good condition?

  Yes

  No

  N/A

• Lighting to the building is in good working condition?

  Yes

  No

  N/A

• The exterior if free from holes/hives/ nests or damage related to pests?

  Yes

  No

  N/A

• Entry ways are free from tripping hazards and maintained according to season?

  Yes

  No

  N/A

• Exterior paint, caulking and tuck-pointing is in good condition?

  Yes

  No

  N/A

• Fences/retaining walls are in good condition?

  Yes

  No

  N/A

• Exterior windows are in good condition?

  Yes

  No

  N/A

• Gutters and downspouts are in good condition?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness issues related to exterior spaces?

  Yes

  No

  N/A