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 #

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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.