Maintenance Presurvey

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Environment Free of Accidents - F323

• Sidewalks free of major cracks and hazards?

  Yes

  No

  N/A

Adequate and Comfortable Lighting in All Areas - F256

• Ramps meet ADA requirements and rails are secure if present?

  Yes

  No

  N/A

• Glare minimized?

  Yes

  No

  N/A

• Bulbs operable?

  Yes

  No

  N/A

• Driveway free of major cracks and potholes?

  Yes

  No

  N/A

• Parking lot has adequate lighting?

  Yes

  No

  N/A

• Evacuation plans posted at each pull station showing location in building and nearest exit?

  Yes

  No

  N/A

• Exit Signs properly illuminated and visible through entire egress route?

  Yes

  No

  N/A

• Corridors are clear of equipment?

  Yes

  No

  N/A

• Doors leading to areas that pose a hazard to residents are locked at all times? All Doors identified with appropriate signs?

  Yes

  No

  N/A

• All electrical receptacles within six feet of a water source are GFI protected?

  Yes

  No

  N/A

• Only approved extension cords are used?

  Yes

  No

  N/A

• All plugs and cords on equipment are in good condition? No ground pins missing?

  Yes

  No

  N/A

• Water temperatures in resident areas not to exceed 120F?

  Yes

  No

  N/A

• Showers have anti-siphon back flow devices and non slip floors or mats?

  Yes

  No

  N/A

Comfortable and Safe Temperature Levels - F257

• Air temperatures between 71F & 81F?

  Yes

  No

  N/A

Dispose of Garbage and Refuse Properly - F372

• Dumpster/Compactor areas are clean?

  Yes

  No

  N/A

• Dumpsters are covered?

  Yes

  No

  N/A

• Waste is properly contained?

  Yes

  No

  N/A

• Infectious waste disposed and stored and properly labeled?

  Yes

  No

  N/A

• All waste scheduled for routine pick-up?

  Yes

  No

  N/A

Infection Control - F441

• All equipment is clean?

  Yes

  No

  N/A

• Ice machines have covered scoops?

  Yes

  No

  N/A

Life Safety Code: Center must be Designed, Constructed, Equipped and Maintained to Protect the Health and Safety of Residents, Personnel and the Public - F454

• Sprinkler System - All components clean and in good repair, replacement heads available and properly stored, wrench available for heads? All required inspections complete and reports available?

  Yes

  No

  N/A

• Flammable Products - Used and stored per manufacturers recommendations? Flammable storage locker clean, orderly and locked?

  Yes

  No

  N/A

• Hazardous Products - Used and stored per manufacturers recommendations, correctly labeled, protective equipment available?

  Yes

  No

  N/A

• Storage Areas - Clean, orderly, storage 6" above floor, 18" below ceiling, 18" below sprinkler heads, paper goods and food stored separate from chemicals?

  Yes

  No

  N/A

• Walls - Free from cracks, peeling paint, stains and cobwebs?

  Yes

  No

  N/A

• Fire Alarm System - Is in good repair, strobes are visible, horns sound? Smoke detectors are clean? All required inspections complete and reports available?

  Yes

  No

  N/A

• Fire Doors - Are labeled with fire rating, not warped or twisted, close properly, are positive latching and panic bars are in good working condition? Have gaps no more than 3/4 at the bottom and no more than 1/8 between doors when closed?

  Yes

  No

  N/A

• Smoke Barrier Doors - Are labeled with fire rating, not warped or twisted, close properly and have gap no more than 3/4 at bottom of door and no more than 1/8 between doors when closed? All Partitions through fire walls, floors and ceilings are sealed with fire rated material? Door stops are NOT in use?

  Yes

  No

  N/A

• Light Shields/Guards - All mechanical rooms, laundry, dietary and storage areas have light shields or guards to protect bulbs?

  Yes

  No

  N/A

• Clean Utility Rooms - Are clean, orderly and safe? No storage under sinks? Personal protective equipment is available?

  Yes

  No

  N/A

• Soiled Utility Rooms - Are clean, orderly and safe? No storage under sinks? Personal protective equipment available?

  Yes

  No

  N/A

• Janitors Closets - Are clean, orderly and safe? Personal protective equipment available?

  Yes

  No

  N/A

• Roof - Is free from bubbles, low spots, standing water, debris and leaks?

  Yes

  No

  N/A

• Gutters & Downspouts - Gutters and down spouts in good repair and drain properly?

  Yes

  No

  N/A

• Entrance - <br><br>Doors and hardware in good condition?<br><br>Drive-thru canopy clearance is marked?

  Yes

  No

  N/A

Emergency Power - F455

• An emergency electrical system must supply power adequate at least for lighting all entrances and exits, equipment to maintain the fire detection, alarm and extinguishing system and life support systems in the event of a normal supply interruption?

  Yes

  No

  N/A

• Generator is operable, belts good, water & oil levels ok?

  Yes

  No

  N/A

• Emergency circuits energized within 10 seconds of startup?

  Yes

  No

  N/A

• System is run weekly and under load monthly?

  Yes

  No

  N/A

• Logs are maintained?

  Yes

  No

  N/A

• Full load bank test completed annually and reports available?

  Yes

  No

  N/A

• Annual preventive maintenance performed and report available?

  Yes

  No

  N/A

Mechanical Rooms

• Boiler Rooms -Boiler in good repair, temp/pressure gauges in operating range, secure utility connections, circulating pumps operating? Room is clean and NOT used for storage? 3ft Clearance maintained around equipment?

  Yes

  No

  N/A

• Electrical / Mechanical Rooms - Are clean, safe and orderly? NOT used for storage? Equipment is in good operating condition?

  Yes

  No

  N/A

• Elevator Rooms - Are clean, safe and orderly? NOT used for storage? Equipment is in good operating condition?

  Yes

  No

  N/A

• Maintenance Shops - Is clean, safe and orderly, equipment in good repair and appropriate safety gear available?

  Yes

  No

  N/A

• Laundry Room - Washers clean, operate properly, belts good, doors and seals good, safety interlock working and free of leaks? Dryers clean, operate properly, belts good, doors and seals good, free of lint build-up in, on and around machines? Lint Screens cleaned every two hours and log maintained?

  Yes

  No

  N/A

• Nourishment Refrigerators - Gaskets in good repair and clean? Thermometer present and temperature logs maintained? Temp range is 34F to 45F?

  Yes

  No

  N/A

• Main Utility Shutoffs - Clearly labeled and location of shutoffs and procedures to operate shutoffs are in Emergency Preparedness Manual?

  Yes

  No

  N/A

• Grab Bars - Grab bars in toilet/shower areas are secure, clean and free of sharp edges?

  Yes

  No

  N/A

• Dietary - All equipment is clean and in good repair?

  Yes

  No

  N/A

• Resident Care Equipment - Lifts, scales, shower chairs, wheelchairs, side rails, beds etc. are clean, safe and in good working condition?

  Yes

  No

  N/A

• Central HVAC - Units are in good working order? Duct work is in good repair, sealed and insulated? Condenser/evaporator clean, fans operable, belts good, grills and filters clean? Filter logs maintained?

  Yes

  No

  N/A

Resident Rooms - F457 - F462

• Accommodates no more than four residents? Measures at least 80 sq ft per resident in multiple bedrooms and 100 sq ft in a single room? Has direct access to exit corridor? Assures full visual privacy? Has at least one window to the outside? Has a floor at or above grade level?

  Yes

  No

  N/A

Toilet Facilities - F462

• Each resident room is equipped with or located near toilet facilities?

  Yes

  No

  N/A

• Plumbing : Toilets and sinks are securely installed and caulked, free of leaks and operate properly?

  Yes

  No

  N/A

Resident Call System - F463

• The nurses station is equipped to receive resident calls through a communication system from resident rooms, toilets and bathing facilities?

  Yes

  No

  N/A

Dining and Resident Activities - F464 - F465

• One or more rooms dedicated to dining and activities?

  Yes

  No

  N/A

• Rooms are well lighted, well ventilated with non-smoking areas identified, adequately furnished and have sufficient space for activities?

  Yes

  No

  N/A

Handrails - F468

• Corridors are equipped with firmly secured handrails on each side?

  Yes

  No

  N/A

• Handrails are clean, secure and free of sharp edges and splinters?

  Yes

  No

  N/A

• Notes:

• Inspected by:

  Sign

• Reviewed by:

  Sign