Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

Nursing Stations

  • 1. Clean and free of clutter

  • 2. No food present, only drinks with a lid

  • 3. Use of hospital-approved hand lotion

  • 4. No resident care supplies left open on tables

  • 5. Trash is not overflowing

  • 6. Lab specimens are not left sitting out or in a biohazard bag/container.

  • 7. Med carts are not cluttered with open medication present.

  • 8. No corrugated cardboard boxes present.


  • 1. daily temperature checks are documented appropriately

  • 2. Items are appropriately labeled and nothing is out of date

  • 3. Refrigerator is clean.

  • 4. Staff do not use the same refrigerator that is used by residents.

  • 5. No pet food stored in same refrigerators as resident or staff food.

Waiting Rooms, Public Bathrooms, Lounge Areas, Dining Rooms and Hallways

  • 1. All horizontal surfaces are clean

  • 2. Areas/hallways are not cluttered

  • 3. Trash is not overflowing

  • 4. Bathrooms are clean

  • 5. Handwashing supplies are available

  • 6. No stained ceiling tiles present

  • 7. Animal cages/tanks are routinely cleaned. (according to policy)

  • 8. Resident chairs are kept in good condition. (No staining, odors, etc.)

  • 9. No Nebulizer treatments being performed.

  • 10. Nurses have access to PPE (gloves, etc.)

  • 11. Nasal cannulas stored in bag when not used.

  • 12. Cloth napkins are covered in the dining area.

  • 13. Garbage cans are kept away from clean supplies/food.

  • 14. Garbage cans have a top on them when not being used.

Kitchen Areas

  • 1. Area is clean and free of clutter.

  • 2. Trash is not overflowing

  • 3. Food items stored in cabinets are sealed or clipped.

  • 4. Food items stored in cabinets are not expired.

  • 5. No pet food stored with resident food.

  • 6. Nothing stored underneath sink.

  • 7. No corrugated cardboard present.


  • 1. Hand hygiene is being performed correctly

  • 2. No fingernail polish or artificial nails. (if providing resident care)

  • 3. Appropriate fingernail length (1/4")

  • 4. Staff understands isolation precaution protocol and needlestick protocol

Hand Hygiene

  • 1. Sinks for handwashing are appropriately stocked with soap, paper towels, and trash cans

  • 2. Alcohol-based hand rubs are available in/outside residents rooms and other resident care areas

  • 3. Gloves are stocked for staff use when in residents' rooms.

  • 4. Staff are assisting residents with hand hygiene (after using bathroom, before eating, etc.)

Transmission-Based Precautions

  • 1. PPE supplies are available for staff and visitors

  • 2. Appropriate signage in place

  • 3. Trash and linen handled per policy

  • 4. Resident and family given appropriate education pertaining to the type of isolation

  • 5. Trash and linens handled per policy

  • 6. If airborne precautions , is the door closed

  • 7. Appropriate PPE being used by staff

  • 8. Isolation stations being utilized and are stocked

  • 9. Residents in an isolation room are not out in resident areas

Soiled Utility

  • 1. Door to room is labeled

  • 2. Biohazard symbol on door

  • 3. Soiled linen in hamper with impervious liner

  • 4. Clean supplies are not in the room

  • 5. Appropriate PPE available

  • 6. Soiled linen covered for transport

Storage/Clean Utility

  • 1. Is there a clear walk way

  • 2. Environment is clean

  • 3. All equipment is clean and stored off the ground

  • 4. Equipment/supplies are not out of date

  • 5. No supplies stored under sink

  • 6. No cardboard boxes present

Clean Linens

  • 1. Linens are in good condition

  • 2. Stored on covered cart or in linen room where shelf is covered

  • 3. Clean linen covered during transport

Resident Care Equipment

  • 1. Equipment is cleaned according to policy/company IFUs

  • 2. Glucometer wiped down and using super sani-cloths (purple top) and left to dry for at least 2 minutes before being used again

  • 3. Vital sign machines are cleaned using the disinfectant wipes before being used

  • 4. Equipment does not has expiration date that is expired.

  • 5. Single-use equipment is discarded after use and is never used on other residents

Hazardous Materials and Medical Waste

  • 1. Appropriate sharps container in use

  • 2. Sharps containers no more than 3/4 full

  • 3. Sharps containers secured to wall or cabinet.

  • 4. Appropriate biomedical waste manifests maintained.

  • 5. Eye wash station checks are logged.

Shower Rooms

  • 1. Room is clean and free of clutter

  • 2. Shower supplies are not expired

  • 3. Shower bays are clean prior to use (in-between residents)

  • 4. PPE is available for staff

COVID-19 Requirements

  • 1. Staff wearing a mask at all time unless eating or in a private room by themselves

  • 2. Staff ensuring residents are wearing a mask will receiving visitors

  • 3. Designated visitation areas are not cluttered and social distancing is being maintained

  • 4. Appropriate PPE and Isolation Precautions used for positive residents

  • 5. CMS guidance followed in regards to testing, visitation, and resident care if positive present

  • 6. Staff help residents social distance while they are eating.

Medication/Injection Practices

  • 1. Injections are prepared using clean technique

  • 2. Needles are used for only one resident

  • 3. Insulin pens are used for only one resident

  • 4. Rubber septum on any medication vial, whether unopened or previously accessed, are disinfected with alcohol prior to piercing

  • 5. Medication vial labeled for single dose only is used only once and for only one resident

  • 6. Multi-dose medication vials are dated when they are first opened and discarded within 28 days unless the manufacturer specifies a different date for that vial

  • 7. Pudding/applesauce not left open on med cart.

  • 8. Pudding/applesauce kept cold on the med cart.

  • 9. Medication is kept in package/sealed until ready to administer.


  • 1. Indwelling catheters secured properly

  • 2. Catheter drainage bag is kept below the level of the bladder and off the floor at all times

  • 3. Catheter bag is emptied using separate, clean collection container for each resident

  • 4. Catheter tubing does not have kinks or loops


  • 1. All cylinders (oxygen, other compressed gas) are secured

  • 2. Empty oxygen tanks are kept separate from full oxygen tanks

  • 3. Fire extinguisher not obstructed from easy access

  • 4. No electrical panels are blocked

  • 5. Hospital furnishings/equipment are kept in good repair (No torn or soiled furniture, wheelchairs, mattresses)

  • 6. Countertops/doors are in good condition with no chipping to laminate

  • 7. No supplies stored under sinks

  • 8. Paper is not present on fire-rated doors

  • 9. Maintains the integrity of egress throughout the unit

  • 10. No space heater present in resident care area

  • 11. There is at least 18" of open space maintained below a sprinkler deflector to the top of storage

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