Title Page

  • Conducted on

  • Prepared by

  • Location

Ceiling

Ceiling Tiles/Grid

  • Stained Ceiling Tiles?

  • Missing Tiles?

  • Gaps in Tiles?

  • Stained and/or Missing Grid?

Lighting

  • Debris in Light Fixtures?

  • Lights Not Working?

Grills

  • Dirty/Dusty Grills?

  • Unsecured Grills?

  • Broken Grills?

Exit Signs

  • Not Lit?

  • Unsecured Signs?

  • Visually Blocked Signs?

Sprinkler Heads

  • Dirty/Dusty Heads?

  • Gaps Around Head?

Walls

Paint

  • Patch Work Needed?

  • Touch-up Needed?

  • Whole Wall/Room Repainted?

Wallpaper

  • Peeling/Stained?

Outlets

  • Unsecured to Wall?

  • Plug Prongs Left Behind?

  • Missing Label?

Handrail/Bump Rails

  • Damaged Rail?

  • Missing Rail?

  • Needed Rail?

Signage/Art

  • Damaged Art/Sign?

  • Missing Art/Sign?

Doors

Frame

  • Unsecured Frame?

  • Missing Latch Plate?

Slab

  • Broken Slab

  • Missing Laminate (Exposed Core)?

Door Hardware

  • Handle/Hinges/Closer Not Working?

Access Control/Door Operator

  • Damaged Hardware?

  • Missing Hardware?

Floors

Flooring

  • Missing/Damaged Flooring

Expansion Joints

  • Missing/Damaged Gaskets

Cove Base

  • Missing/Damaged Cove Base

Transition Strips

  • Missing/Damaged Strips

Slips/Trips Hazards

  • Describe:

Equipment

Bathrooms

  • Toilets (Describe the Issue)

  • Sinks (Describe the Issue)

  • Dispensers (Describe the Issue)

Patient Rooms

  • Headwall Equipment (Describe the Issue)

  • Phone (Describe the Issue)

  • Pillow Speaker (Describe the Issue)

  • TV (Describe the Issue)

Exterior

Surface Lots

  • Potholes?

  • Drainage blocked?

Sidewalks

  • Cracks and/or Unsafe Elevations?

Irrigation

  • Improper Spraying?

  • Bad Head?

  • Exposed Sprinkler Lines

Delineation

  • Lines and/or Delineators Faded/Missing?

Equipment

  • Cones/Jersey Barriers/Powered Gates (Describe the Issue)

Roofing

Roofing Integrity

  • Roof Breach?

  • Drains clogged?

Safety Checks

  • Debris that can be blown off of roof?

  • Wires and/or Trip Hazards Not Secured?

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