General Information

GENERAL INFORMATION

Has last inspection been reviewed?

Are there any outstanding issues from last inspection

Resident Rooms

RESIDENT ROOMS

Free of objectionable odors

Ceilings clean and free of stains and marks

Ceiling vents clean

Fire sprinkler heads and pipe clean of dust, paint or other obstructions

Light lenses clean and free of debris (insects, etc...)

Lights bulbs all illuminate

Over bed light operational and free of dust and obstructions

Night light operational

Privacy curtains clean and free of holes and stains

Walls clean and free of spots and stains

Walls free of peeling paint and excessive damage

Window treatments clean and in good repair

Window glass free of finger prints and spots

Window screens in good repair

Baseboard heating vents clean, in good repair and free of dust

Artwork and decorations on walls free of dust

Ledges, window sils and shelves are free of dust and debris

Carpeting clean of dirt, dust and litter including corners

Carpeting is free of stains

Vinyl floors free of dirt, dust, litter including corners

Floors waxed, polished and free of marks from wheelchairs and walkers

Baseboard are free of buildup of dirt and wax

Floors are free of slip/trip/fall hazards

Nurse call cords clean, intact and functional

Furniture is in good repair

Bed and frame is clean

Overbed table clean including base and wheels

Oxygen and other storage is appropriate

IV, Tube Feeding stands clean including base and wheels

Room is decorated and homelike

Sharps containers are readily available, removed when 3/4 full and not accessible to residents

Personal care items are sanitized and properly stored (Basins, bed pans, urinals, etc...)

COMMENTS / RECOMMENDATIONS

RESIDENT BATHROOMS

Bathroom lighting functional

Bathroom mirror is free of debris and streaking

Bathroom ventilation is working

Bathroom commode is clean and free of stains

Bathroom is stocked with soap, paper towels and toilet tissue

Sink is clean, free of soap and other buildup including any exposed piping

Grab bars for showers and toilets are present, clean and secure

Commode chairs are clean and in good repair

Floors are free of slip/trip/fall hazards

COMMENTS / RECOMMENDATIONS

Restrooms, Public

RESTROOMS, PUBLIC / STAFF

Free of objectionable odors

Ceiling vents clean

Ventilation is working

Ceilings clean and free of stains and marks

Fire sprinkler heads and pipe clean of dust, paint or other obstructions

Light lenses clean and free of debris (insects, etc...)

Lights bulbs all illuminate

Walls clean and free of spots and stains

Walls free of peeling paint and excessive damage

Baseboard are free of buildup of dirt and wax

Artwork and decorations on walls free of dust

Bathroom mirror is free of debris and streaking

Sink is clean, free of soap and other buildup including any exposed piping

Grab bars for toilets are present, clean and secure

Bathroom toilet is clean and free of stains

Bathroom is stocked with soap, paper towels and toilet tissue

Floor drains have grates covering piping

Floors free of dirt, dust, litter including corners

Floor is free of slip/trip/fall hazards

Floors waxed, polished and free of marks

COMMENTS / RECOMMENDATIONS

Spa / Bathing Rooms

TUB ROOMS

Free of objectionable odors

Ceilings clean and free of stains and marks

Ceiling vents clean

Fire sprinkler heads and pipe clean of dust, paint or other obstructions

Light lenses clean and free of debris (insects, etc...)

Lights bulbs all illuminate

Walls clean and free of spots and stains

Walls free of peeling paint and excessive damage

Artwork and decorations on walls free of dust

Vinyl floors free of dirt, dust, litter including corners

Floors waxed, polished and free of marks from wheelchairs and walkers

Baseboard are free of buildup of dirt and wax

Floor is free of slip/trip/fall hazards

Sharps containers are readily available, removed when 3/4 full and not accessible to residents

Shower chairs are disinfected after each use

Whirlpool tubs are disinfected and cleaned after each use

Chemicals are properly labeled and stored in a locked area

Room ventilation is operational

Floor drains have grates covering piping

Bathing surfaces are non slip

Water temperatures are taken at least weekly and logged indicating within acceptable range

COMMENTS / RECOMMENDATIONS

RESTROOM / SHOWER

Bathroom lighting functional

Bathroom mirror is free of debris and streaking

Bathroom ventilation is working

Bathroom commode is clean and free of stains

Bathroom is stocked with soap, paper towels and toilet tissue

Sink is clean, free of soap and other buildup including any exposed piping

Grab bars for showers and toilets are present, clean and secure

Floors are free of slip/trip/fall hazards

COMMENTS / RECOMMENDATIONS

Utility Room, Clean

UTILITY ROOM, CLEAN

Free of objectionable odors

Ceilings clean and free of stains and marks

Ceiling vents clean

Fire sprinkler heads and pipe clean of dust, paint or other obstructions

Light lenses clean and free of debris (insects, etc...)

Lights bulbs all illuminate

Walls clean and free of spots and stains

Walls free of peeling paint and excessive damage

Floors waxed, polished and free of marks from wheelchairs and walkers

Vinyl floors free of dirt, dust, litter including corners

Baseboard are free of buildup of dirt and wax

Floor is free of slip/trip/fall hazards

Floor is free of storage on the floor

COMMENTS / RECOMMENDATIONS

Utility Room, Soiled

UTILITY ROOM, SOILED

Door signage for bio-hazard

Free of objectionable odors

Ceilings clean and free of stains and marks

Fire sprinkler heads and pipe clean of dust, paint or other obstructions

Ceiling vents clean

Light lenses clean and free of debris (insects, etc...)

Lights bulbs all illuminate

Walls clean and free of spots and stains

Walls free of peeling paint and excessive damage

Floors waxed, polished and free of marks from wheelchairs and walkers

Vinyl floors free of dirt, dust, litter including corners

Floors free of slip/trip/fall hazards

Baseboard are free of buildup of dirt and wax

Floor is free of slip/trip/fall hazards

Utility hopper sink is clean and in working order, hoses hung properly

Dirty linen barrels/hampers remain covered and emptied when necessary

Dirty linen barrels cleaned per facility schedule (Identify schedule of this event)

Gloves, gowns and eye protection are available

Disinfectant is stocked and available

Chemicals are properly labeled and stored in a locked area

Trash / Garbage (non contaminated) is not placed in bio-hazard container

Sinks are clean

No storage under sink cabinets

COMMENTS / RECOMMENDATIONS

Vestibule

VESTIBULE

Ceilings clean and free of stains and marks

Walk off mats clean, adequate and in proper locations

Fire sprinkler heads and pipe clean of dust, paint or other obstructions

Light lenses clean and free of debris (insects, etc...)

Lights bulbs all illuminate

Walls clean and free of spots and stains

Walls free of peeling paint and excessive damage

Window treatments clean and in good repair

Window glass free of finger prints and spots

Window screens in good repair

Baseboard heating vents clean, in good repair and free of dust

Ledges, window sils and shelves are free of dust and debris

Flooring clean of dirt, dust and litter including corners

Baseboard are free of buildup of dirt and wax

Floors are free of slip/trip/fall hazards

COMMENTS / RECOMMENDATIONS

Exit Conference

EXIT CONFERENCE and SIGNATURES

COMMENTS / RECOMMENDATIONS

Date and time the audit was concluded and exit conference held
NAME and SIGNATURE OF ST ANNS HOME STAFF COMPLETING AUDIT
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.