Title Page

  • Report Title:

  • Client/Site:

  • Conducted on

  • Date Constructed:

  • Facility Front with Signage

  • Prepared by

General Conditions

  • Describe the general impression of the facility:

  • Is the facility sign in good condition?

  • Does the facility have blueprints?

  • How Many Occupied Building?

  • How many outbuildings?

  • Is the facility free from any Asbestos containing material?

  • Does the facility have an asbestos material control plan, and is any remaining material in a non-friable condition?

  • Detail what materials and locations, or attach asbestos report if available.

Entrance

  • Does the front entrance have an automatic opening door that is ADA compliant?

  • Does the front entry have a mag-lock or other security measure?

  • Does the entrance have a patient elopement system installed?

  • Entrance is free from trip hazards?

  • Entrance to the facility does not create risk for a fall?

  • Facility entrance has handrails or is configured for safe access?

  • Facility entrance to meets code and does not require any repairs?

  • Are all exterior entrances to the facility safe from obvious hazards and are in good condition?

Exterior Envelope

  • What type of construction is the exterior of the facility?

  • What is the condition of the paint and finish on the exterior of the building?

  • What is the condition of the soffit?

  • What is the condition of the facia?

  • What type of windows are installed?

  • Are all windows double pane?

  • List type and location of windows:

  • Are all windows in working condition with screens and latches?

  • Do all windows and doors positively shut and latch (applicable code)?

Parking Lot

  • What is the general condition of the parking lot(s)?

  • All areas in good condition with no needed repairs?

  • List each area and provide pictures of needed work:

  • Is the parking lot and building exterior adequately lit at night for security? (1-5 fc)?

  • Do all parking areas have bumpers or curbs?

  • What condition is the parking lot line striping?

  • Are all ADA Markings or signs clear and to code?

  • How many Parking Slots are on the property(non-ADA)?

  • How many ADA- parking slots are on the property?

  • What is the general condition of the facility sidewalks?

  • Are all sidewalks in good condition with no needed repairs?

  • Describe needed repairs and attach pictures:

  • Are all sidewalks ADA complaint (ramps as required)?

  • Is the garbage area clean and free of excessive odors?

  • Does the facility use a trash compactor?

  • Describe the condition of the trash compactor:

  • Describe specific repairs needed and pictures as needed.

Landscaping

  • What is the general condition of the facility landscaping?

  • Who is the facility landscape contractor(provide contact number)?

  • Is there a functioning irrigation sprinkler system?

Fencing

  • Does the facility have any fences on the property?

  • What is the general condition of any fences on the property?

  • Do all gates open and close properly?

  • Is panic hardware installed on any secured gates if they are in a evacuation pathway?

  • Fences do not require any repair or replacement?

Roof/Gutters

  • What is the general condition of the roof?

  • Describe the roof composition(3-tab, membrane, tile ect.) of each section as appropriate and age:

  • Roofs are free from ponding or standing water?

  • Drains are properly installed to avoid standing water?

  • Are tree's cut back 3 feet from roof-line?

  • Is the roof system clean and well maintained?

  • Are a all gutters clean and draining properly?

  • Are splash-blocks or site drainage positioned for each downspout?

Generator

  • Does the facility have an emergency generator?

  • Describe the general condition of the Generator and Automatic Transfer Switch?

  • Location:

  • Make:

  • Model:

  • Age:

  • Size(KW):

  • Fuel Type:

Fire Alarm

  • What is the general condition of the Fire Alarm system?

  • Make:

  • Has the system been service in the last 12 month, and no deficiencies or repairs needed?

  • Model:

  • FACP Location:

  • Installed Date:

  • Is the Fire Alarm system Addressable or Zoned?

  • Describe system and the locations each portion serves:

Nurse Call

  • How many nurse call systems are in the facility?

  • Describe the general condition of the nurse call system(s)

  • How many Annunciation Panels in the facility?

  • How many Resident Call Stations?

  • How many bathroom or shower room call stations?

  • Is the nurse call system operational with no needed repairs?

Interior of Facility

  • Does the facility have a dedicated reception area?

  • What is the condition of the flooring in the lobby area (take picture and note type of material)?

  • What is the condition of the flooring in the corridors (take pictures and note what type of material?

  • What is the general condition of the common spaces (walls, wall covering, artwork ect)?

  • Is the lighting in the common spaces adequate?

  • What is the general condition of the handrails?

  • What is the condition of the doors in the corridor?

  • Describe needed repairs or improvements and take pictures as appropriate:

  • Are all resident door and bathrooms ADA lever set door knobs?

  • Do all facility entrances and exit able to be secured staff?

  • Describe needed repairs or changes to provide for adequate security:

  • Does the staff have any concerns regarding security?

  • Describe specific concerns and staff names for follow-up.

Resident Rooms

  • What is the general condition of the resident rooms?

  • What condition is the flooring in resident rooms and bathrooms?

  • Describe the flooring type and age for the resident room and bathrooms:

  • What is the general condition of the plumbing fixtures in the resident rooms?

  • What is the condition of the facility equipment?

  • Please describe any additional repairs or equipment needed and provide photo graphs and documentation as appropriate:

Kitchen

  • What is the general condition of the kitchen?

  • Is the kitchen clean and organized?

  • What type of suppression system is installed in the kitchen hood?

  • What is the Make of the Suppression system?

  • What is the model of the suppression system?

  • Has the kitchen hood and suppression system been inspected every 6 months by a service company?

  • Service Date #1: (mm/dd/yy)

  • Service Date #2: (mm/dd/yy)

  • Has the kitchen hood been cleaned in the last 12 months?

  • Are all hood baffles tightly fitting with no gaps or movement when unit is turned on?

  • Is the facility dish machine owned or leased?

  • Who is the leasing company?

  • Is the dish machine a high temp (booster) or low temp (chemical injection) machine?

  • Has the booster been serviced in the last 6 months?

  • Does the dish machine records indicate that the rinse temp reaches 180 F?

  • Does the final rinse temp exceed 120 degrees, and records indicate chlorine level is above 200 ppm?

  • Are the facility ice machines drained, cleaned, and filters checked quarterly?

  • What is the location of the facility grease trap and has records of being routinely maintained?

  • All kitchen and equipment are in good condition, no repairs or replacement needed?

  • Describe the needed repairs or replacements, photograph as necessary.

  • Does the facility have a deep fryer?

  • Is that equipment kept under the hood and at least 16" from any potential ignition source?

  • In the last 12 months has the facility had any issue with buildup of any Fats, Oils, or grease issues requiring service work?

Refrigerators/ Freezers

  • How many Reach-in Refrigerators are onsite?

  • How many Reach-in Freezers are onsite?

  • How many Walk-in Refrigerators are onsite?

  • How many Walk-in Freezers are onsite?

  • What is the average age of the refrigeration equipment ?

  • Refrigeration Equipment is in good condition and needs no repairs or replacements?

  • Describe and needed repairs or replacements:

Laundry

  • Does the facility have an on-site laundry?

  • What is the general condition of the laundry area( clean, organized, good repair)?

  • How many tumblers are on site?

  • How many extractors are on site?

  • What is the average age of the equipment?

  • Laundry Equipment is in working condition, no repairs or replacements needed?

  • Describe issue or repairs:

Electrical

  • Facility has no identified electrical issues?

  • Describe issue or repairs needed (photos as needed).

  • Has the facility had the electrical service inspected and thermal scan per NFPA 70 in the past 5 years?

  • Does the facility have a lockout/tag out program and current training?

  • Are quarterly inspections and logs of GFI testing being done?

  • Is the facility testing receptacle tension to ensure safe electrical receptacles in patient care areas?

Plumbing

  • How many water heaters are on site?

  • How many boilers are on site?

  • Is the water management plan and flow diagram accurate?

  • What is the general condition of the water heating systems?

  • Describe the types of water heating or boiler equipment is in service?

  • Facility needs no additional water heating related equipment repairs or replacements?

  • Describe needed repairs or replacements and estimate of cost.

  • Are all hot water appliances set to deliver the correct temperature of water for their application?

  • How many mixing valves are in operation, major distribution, showers. (not tempering valves i.e. sinks)

  • Does the facility have a water softening system?

  • Does the Facility have any plumbing or sewer repairs presently?

  • Describe repairs or replacements needed:

  • Has there been any sewer or subterranean issues in the last 12 months?

  • Describe situation and any mitigations performed.

HVAC

  • What is the general condition of the HVAC systems in the facility?

  • Are there any specific HVAC unit repairs or replacements needed?

  • Describe repairs or replacement as necessary:

  • Are all the HVAC units labeled indicating coordinating systems?

  • Are all HVAC filters dated and replaced per their PM schedule?

  • Are all exhaust fans functioning and clean?

  • Exposed duct work do not show any signs of leaking or deterioration?

  • Are all HVAC discharges and returns balanced and clean?

  • Resident Room heat is provided by what type of system(select all as needed)?

  • Resident Room Cooling is provided by what type of system(select all as needed)?

  • Does the facility have defined plans to provide alternate heating / cooling during extreme weather?

Elevator

  • Does the facility have an elevator?

  • How many are on site?

  • Who is the service company?

  • When was the last date of service?

  • Was the service completed in the last 12 months?

  • Is the permit current and on file?

  • Was the elevator shaft and sump clean?

Capital Projects

  • Facility Identified Top 5 Capital Projects:

  • Capital Projects:
  • Describe Scope and budgeted cost of project:

  • Pictures supporting project.

Facility Needs (Other)

  • Please document any other facility issues:

  • Issue #
  • Add media

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