General Information

Photograph of Site
Photograph(s) of Community Exterior
WEATHER CONDITIONS

Cloudy

Dusty

Fog

Freezing rain / ice

Hail

Lightning

Rain

Sleet

Snow

Sunny

Thunder Storm

Windy

Temperature

Humidity

GENERAL DEMOGRAPHIC INFORMATION

Provider ID Number

License / Facility ID Number

Level(s) of Care

Skilled Nursing

SNF Beds / Rooms

Home for Aged

HFA Beds / Rooms / Apartments

Assisted Living

Assisted Living Beds / Rooms / Apartments

Adult Foster Care

AFC Beds / Rooms / Apartments

Memory Care

Memory Care Beds / Rooms / Apartments

Independent Living

Studio Apartments

One Bedroom Apartments

Two Bedroom Apartments

Companion or Shared Apartments

PREVIOUS AUDITS / INSPECTIONS

Has last inspection been reviewed?

Are there any outstanding issues from last inspection

Is the community required to have a CLIA Waiver? If so, is it current? (attach Other Photographs)

Does the community have a valid Medical Waste Generator certificate? (attach Other Photographs)

Other Photographs

COMMENTS / RECOMMENDATIONS

Broom / Janitor Closet

BROOM / JANITOR CLOSET

Broom / Janitor closet door has signage for emergency eye wash station.

Broom / Janitor closet door is free of damage and in good repair.

Broom / Janitor closet free of objectionable odors.

Broom / Janitor closet ceiling vents clean.

Broom / Janitor closet ventilation is working.

Broom / Janitor closet ceilings clean and free of stains and marks.

Broom / Janitor closet fire sprinkler heads and pipe clean of dust, paint or other obstructions.

Broom / Janitor closet has no evidence of high pile storage.

Broom / Janitor closet lighting functional.

Broom / Janitor closet light lenses clean and free of debris (insects, etc...).

Broom / Janitor closet lights bulbs all illuminate.

Broom / Janitor closet walls clean and free of spots and stains.

Broom / Janitor closet walls free of peeling paint and excessive damage.

Broom / Janitor closet ledges, window sills and shelves are free of dust and debris.

Broom / Janitor closet hand wash sink is clean, free of soap and other buildup including any exposed piping.

Broom / Janitor closet floor sink is clean and in working order, hoses hung properly.

Broom / Janitor closet baseboard and/or heating vents clean, in good repair and free of dust.

Broom / Janitor closet floors free of dirt, dust, litter including corners.

Broom / Janitor closet floor is free of slip/trip/fall hazards.

Broom / Janitor closet baseboard are free of buildup of dirt and wax.

Broom / Janitor closet trash / garbage (non contaminated) is not placed in bio-hazard container.

Broom / Janitor closet appropriate style emergency eyewash station is available

Broom / Janitor closet gloves, gowns and eye protection are available.

Broom / Janitor closet chemicals are properly labeled and stored.

Broom / Janitor closet trash barrels are covered.

Other Photographs

COMMENTS / RECOMMENDATIONS

Building Exterior, Entrances, Landscaping, Parking and Walkways

BUILDING EXTERIOR

Exterior siding and brick in good repair

Exterior signage is appropriate for way finding.

Exterior signage is in good repair.

Exterior trim of the building is in good repair

Fences are aesthetic in appearance.

Fences are in good repair.

Outbuildings are in good repair.

Refuse compactors are odor free and area around them are clean

Refuse containers are adequate in size and not overflowing.

Refuse containers are located in an enclosure.

Refuse containers lids are closed.

Other Photographs

COMMENTS / RECOMMENDATIONS

ENTRANCES

Entrance awnings, overhangs are clean and in good repair

Entrance door signage stating NO SMOKING CAMPUS is in place.

Entrance door sweeps restrict the passage of light

Entrance fire sprinkler heads and pipe clean of dust, paint or other obstructions

Entrance window glass free of finger prints.

Entrances are well lit

Entrances cigarette urns clean and free of trash and litter

Entrances free of visible cigarette butts

Other Photographs

COMMENTS / RECOMMENDATIONS

LANDSCAPING

Landscaping is free of weeds and overgrown bushes and other plantings.

Lawns and landscaping attractive and clear of litter and debris.

Lawns are cut and free of weeds.

Underground sprinkling available .

Underground sprinkling uses a well.

Other Photographs

COMMENTS / RECOMMENDATIONS

PARKING

Driveway curb cuts are appropriate and unobstructed.

Parking area is well lit

Parking for handicapped is adequate.

Parking for handicapped is marked with stripes and appropriate signage.

Parking handicapped ramp to walkway available and un-obstructed.

Parking is adequate.

Parking lot drainage is appropriate and no ponding of water.

Parking lot striping is visible and defines parking spots clearly

Parking lots free of trash and litter.

Parking lots in good repair, free of potholes.

Other Photographs

COMMENTS / RECOMMENDATIONS

WALKWAYS

Walkways clean of snow and ice

Walkways do not present fall hazards

Walkways do not present fall hazards (uneven surfaces, Ice).

Walkways free of trash and litter.

Walkways free of visible cigarette butts

Walkways from exits to the public way are clean and usable.

Other Photographs

COMMENTS / RECOMMENDATIONS

Dining/Hearth / Kitchen / Pantry

DINING/HEARTH AREA SANCTUARY NEIGHBORHOOD

Dining/Hearth door is free of damage and in good repair.

Dining/Hearth free of objectionable odors.

Dining/Hearth ceiling vents clean.

Dining/Hearth ventilation is working.

Dining/Hearth ceilings clean and free of stains and marks.

Dining/Hearth fire sprinkler heads and pipe clean of dust, paint or other obstructions.

Dining/Hearth no evidence of high pile storage.

Dining/Hearth lighting functional.

Dining/Hearth light lenses clean and free of debris (insects, etc...).

Dining/Hearth lights bulbs all illuminate.

Dining/Hearth walls clean and free of spots and stains.

Dining/Hearth walls free of peeling paint and excessive damage.

Dining/Hearth window treatments clean and in good repair

Dining/Hearth window glass free of finger prints and spots

Dining/Hearth windows are free of moisture between panes of glass.

Dining/Hearth windows are free from drafts.

Dining/Hearth ledges, window sills and shelves are free of dust and debris.

Dining/Hearth window screens in good repair.

Dining/Hearth television and remote control are available and functioning.

Dining/Hearth dvd player / Xbox / Wii are available and functioning

Dining/Hearth artwork and decorations on walls free of dust.

Dining/Hearth floors free of dirt, dust, litter including corners.

Dining/Hearth floor is free of slip/trip/fall hazards.

Dining/Hearth floors waxed, polished and free of marks.

Dining/Hearth baseboard are free of buildup of dirt and wax.

Dining/Hearth carpeting clean of dirt, dust and litter including corners.

Dining/Hearth carpeting is free of stains / odors.

Dining/Hearth furniture is in good repair.

Dining/Hearth furniture is clean and free of odors.

Dining/Hearth area free of clinical equipment when not in active use.

Other Photographs

COMMENTS / RECOMMENDATIONS

NEIGHBORHOOD KITCHEN

Neighborhood kitchen, door is free of damage and in good repair.

Neighborhood kitchen, ceilings clean and free of stains and marks

Neighborhood kitchen, ceiling vents clean

Neighborhood kitchen, fire sprinkler heads and pipe clean of dust, paint or other obstructions

Neighborhood kitchen, has no evidence of high pile storage

Neighborhood kitchen, light lenses clean and free of debris (insects, etc.)

Neighborhood kitchen, light bulbs illuminate

Neighborhood kitchen, walls clean and free of spots and stains

Neighborhood kitchen, walls free of peeling paint and excessive damage

Neighborhood kitchen, window glass free of fingerprints and spots

Neighborhood kitchen, window screens in good repair

Neighborhood kitchen, ledges, windowsills and shelves are free of dust and debris

Neighborhood kitchen, floors free of dirt, dust, litter including corners.

Neighborhood kitchen, floors are free of slip/trip/fall hazards

Neighborhood kitchen, anti-fatigue mats clean adequate and in proper locations

Neighborhood kitchen, garbage receptacles have covers, lined with plastic bags and emptied regularly

Neighborhood kitchen, supplies are stored in an organized and neat manner

Neighborhood kitchen, storage of items is designed to encourage proper ergonomics which allows heaviest items closest to the floor

Other Photographs

COMMENTS / RECOMMENDATIONS

NEIGHBORHOOD PANTRY

Neighborhood pantry, door is free of damage and in good repair.

Neighborhood pantry, ceilings clean and free of stains and marks

Neighborhood pantry, ceiling vents clean

Neighborhood pantry, fire sprinkler heads and pipe clean of dust, paint or other obstructions

Neighborhood pantry, has no evidence of high pile storage

Neighborhood pantry, light lenses clean and free of debris (insects, etc.)

Neighborhood pantry, light bulbs illuminate

Neighborhood pantry, walls clean and free of spots and stains

Neighborhood pantry, walls free of peeling paint and excessive damage

Neighborhood pantry, floors free of dirt, dust, litter including corners.

Neighborhood pantry, floors are free of slip/trip/fall hazards

Neighborhood pantry, supplies are stored in an organized and neat manner

Neighborhood pantry, storage of items is designed to encourage proper ergonomics which allows heaviest items closest to the floor

Neighborhood pantry, equipment is clean and in good working order.

Other Photographs

COMMENTS / RECOMMENDATIONS

Hallways and Corridors

HALLWAYS / CORRIDORS

Hallways free of objectionable odors.

Hallways ceilings clean and free of stains and marks

Hallways ceiling vents clean

Hallways fire sprinkler heads and pipe clean of dust, paint or other obstructions

Hallways no evidence of high pile storage

Hallways light lenses clean and free of debris (insects, etc...)

Hallway lights bulbs all illuminate

Hallway walls clean and free of spots and stains

Hallway walls free of peeling paint and excessive damage

Hallway window treatments clean and in good repair

Hallway window glass free of finger prints and spots

Hallway window screens in good repair

Hallway baseboard heating vents clean, in good repair and free of dust

Hallway artwork and decorations on walls free of dust

Hallway wedges, window sills and shelves are free of dust and debris

Hallway carpeting clean of dirt, dust and litter including corners

Hallway carpeting is free of stains

Hallway vinyl floors free of dirt, dust, litter including corners

Hallway floors waxed, polished and free of marks from wheelchairs and walkers

Hallway baseboard are free of buildup of dirt and wax

Hallway floors are free of slip/trip/fall hazards

Hallways are free of obstructions from equipment not currently in use >30 minutes

Hallway handrails on both sides of hallway are clean and secure and free of hazards

Other Photographs

COMMENTS / RECOMMENDATIONS

Kitchen - Commercial

KITCHEN - COMMERCIAL

Kitchen door is free of damage and in good repair.

Kitchen ceilings clean and free of stains and marks

Kitchen ceiling vents clean

Kitchen fire sprinkler heads and pipe clean of dust, paint or other obstructions

Kitchen has no evidence of high pile storage

Kitchen light lenses clean and free of debris (insects, etc.)

Kitchen light bulbs illuminate

Kitchen walls clean and free of spots and stains

Kitchen walls free of peeling paint and excessive damage

Kitchen window glass free of fingerprints and spots

Kitchen window screens in good repair

Kitchen ledges, windowsills and shelves are free of dust and debris

Kitchen floors free of dirt, dust, litter including corners.

Kitchen floors are free of slip/trip/fall hazards

Kitchen anti-fatigue mats clean adequate and in proper locations

Kitchen garbage receptacles have covers, lined with plastic bags and emptied regularly

Kitchen supplies are stored in an organized and neat manner

Kitchen storage of items is designed to encourage proper ergonomics which allows heaviest items closest to the floor

Other Photographs

COMMENTS / RECOMMENDATIONS

KITCHEN STORAGE

Kitchen storage, door is free of damage and in good repair.

Kitchen storage, ceilings clean and free of stains and marks

Kitchen storage, ceiling vents clean

Kitchen storage, fire sprinkler heads and pipe clean of dust, paint or other obstructions

Kitchen storage, has no evidence of high pile storage

Kitchen storage, light lenses clean and free of debris (insects, etc.)

Kitchen storage, light bulbs illuminate

Kitchen storage, walls clean and free of spots and stains

Kitchen storage, walls free of peeling paint and excessive damage

Kitchen storage, floors free of dirt, dust, litter including corners.

Kitchen storage, floors are free of slip/trip/fall hazards

Kitchen storage, supplies are stored in an organized and neat manner

Kitchen storage, storage of items is designed to encourage proper ergonomics which allows heaviest items closest to the floor

Kitchen storage, equipment is clean and in good working order.

Other Photographs

COMMENTS / RECOMMENDATIONS

KITCHEN EQUIPMENT

Are oven mitts available?

Are oven mitts in good condition? (i.e.. no holes, no split seams, etc.)

Are oven mitts used when necessary?

garbage disposals with a throat opening larger than 4 inches need a guard, other than the regular rubber insert

FOOD SLICERS, ELECTRIC

Ensure that all operators receive on-the-job training under the direct supervision of experienced operators until they can work safely on their own.
Use warning signs to alert employees of the hazard and safety instructions.
Instruct operators to use plungers to feed food into chute-fed slicers. For other slicers, they should use the feeding attachment located on the food-holder.
Never place food into the slicer by hand-feeding or hand pressure.
Instruct operators to retract the slicer blade during cleaning operations.
Instruct operators to turn off and unplug slicers when not in use or when left unattended for any period of time.
Perform servicing and maintenance under an energy control program in accordance with the Control of hazardous energy (lockout/tag out), 29 CFR 1910.147, standard. You can avoid slicer lockout/tag out if the equipment is cord-and-plug connected equipment simply by having exclusive control over the attachment plug after you shut the slicer off and unplug it from the energy source.

Slicers are unplugged when not in use

Walk in refrigerators have a functioning thermometer indicating temperature of <41 F

Walk in refrigerators have a functioning Interior safety release to prevent accidental entrapment.

Walk in refrigerators have a functioning thermometer indicating temperature of <0 F

Walk in freezers have a functioning Interior safety release to prevent accidental entrapment.

Walk in refrigerators have a functioning thermometer indicating temperature of <0 F

Other Photographs

COMMENTS / RECOMMENDATIONS

Laundry Operations

LAUNDRY OPERATIONS

Laundry room free of objectionable odors

Laundry room ceilings clean and free of stains and marks

Laundry room ceiling vents clean.

Laundry room fire sprinkler heads and pipe clean of dust, paint or other obstructions.

Laundry room has no evidence of high pile storage.

Laundry room light lenses clean and free of debris (insects, etc...).

Laundry room lights bulbs all illuminate.

Laundry room walls clean and free of spots and stains.

Laundry room walls free of peeling paint and excessive damage.

Laundry room sinks are clean.

Laundry room baseboard heating vents clean, in good repair and free of dust.

Laundry room baseboard are free of buildup of dirt and wax.

Laundry room floors are free of slip/trip/fall hazards.

Other Photographs.

COMMENTS / RECOMMENDATIONS

EQUIPMENT

Equipment washer(s) in working order.

Equipment washer chemical dispensers in good working order.

Equipment washer chemical dispensers free of buildup of chemicals.

Equipment dryers are free of excessive lint built up.

Equipment staff can articulate the process for checking and cleaning lint from dryers.

Equipment rear of dryers are free of lint and debris buildup.

Equipment dryer ducts are clean.

Personal protective equipment gloves, gowns, eye protection and emergency eyewash are readily available.

Equipment heat label marking systems protect staff from burns and are turned off when not in active use.

Other Photographs.

COMMENTS / RECOMMENDATIONS

Neighborhood Laundry

NEIGHBORHOOD LAUNDRY

Neighborhood laundry free of objectionable odors

Neighborhood laundry ceilings clean and free of stains and marks

Neighborhood laundry ceiling vents clean.

Neighborhood laundry fire sprinkler heads and pipe clean of dust, paint or other obstructions.

Neighborhood laundry has no evidence of high pile storage.

Neighborhood laundry light lenses clean and free of debris (insects, etc...).

Neighborhood laundry lights bulbs all illuminate.

Neighborhood laundry walls clean and free of spots and stains.

Neighborhood laundry walls free of peeling paint and excessive damage.

Neighborhood laundry sinks are clean.

Neighborhood laundry baseboard heating vents clean, in good repair and free of dust.

Neighborhood laundry baseboard are free of buildup of dirt and wax.

Neighborhood laundry floors are free of slip/trip/fall hazards.

Other Photographs.

COMMENTS / RECOMMENDATIONS

EQUIPMENT

Equipment washer(s) in working order.

Equipment washer chemical dispensers in good working order.

Equipment washer chemical dispensers free of buildup of chemicals.

Equipment dryers are free of excessive lint built up.

Equipment staff can articulate the process for checking and cleaning lint from dryers.

Equipment rear of dryers are free of lint and debris buildup.

Equipment dryer ducts are clean.

Personal protective equipment gloves, gowns, eye protection and emergency eyewash are readily available.

Equipment heat label marking systems protect staff from burns and are turned off when not in active use.

Other Photographs.

COMMENTS / RECOMMENDATIONS

Mechanical / Electrical / Plumbing

MECHANICAL ROOM

Mechanical Room door signage for emergency eye wash station.

Mechanical Room door is free of damage and in good repair.

Mechanical Room free of objectionable odors.

Mechanical Room ceiling vents clean.

Mechanical Room ventilation is working.

Mechanical Room ceilings clean and free of stains and marks.

Mechanical Room fire sprinkler heads and pipe clean of dust, paint or other obstructions.

Mechanical Room has no evidence of high pile storage.

Mechanical Room lighting functional.

Mechanical Room light lenses clean and free of debris (insects, etc...).

Mechanical Room lights bulbs all illuminate.

Mechanical Room walls clean and free of spots and stains.

Mechanical Room walls free of peeling paint and excessive damage.

Mechanical Room baseboard and/or heating vents clean, in good repair and free of dust.

Mechanical Room floors free of dirt, dust, litter including corners.

Mechanical Room floor is free of slip/trip/fall hazards.

Mechanical Room baseboard are free of buildup of dirt.

Mechanical Room floors are coated with a slip resistant surface.

Mechanical Room gloves and eye protection are available.

Mechanical Room chemicals are properly labeled and stored.

Mechanical Room trash barrels are covered.

Mechanical Room is not used for storage.

Mechanical Room has no evidence of standing water on the floor.

Mechanical Room piping appropriately labeled.

Mechanical Room adequate direct combustion air.

Mechanical Room boilers are maintained by a qualified individual or firm. (List Name)

Mechanical Room boilers have has a CSD-1 completed in the last 12 months.

Other Photographs

COMMENTS / RECOMMENDATIONS

ELECTRICAL ROOM

Electrical Room door is free of damage and in good repair.

Electrical Room ceiling vents clean.

Electrical Room ventilation is working.

Electrical Room ceilings clean and free of stains and marks.

Electrical Room fire sprinkler heads and pipe clean of dust, paint or other obstructions. (There may be a UL 300 wet agent serving this area or no sprinkler head at all)

Electrical Room has no evidence any type of storage.

Electrical Room lighting functional.

Electrical Room light lenses clean and free of debris (insects, etc...).

Electrical Room lights bulbs all illuminate.

Electrical Room walls clean and free of spots and stains.

Electrical Room walls free of peeling paint and excessive damage.

Electrical Room baseboard and/or heating vents clean, in good repair and free of dust.

Electrical Room floors free of dirt, dust, litter including corners.

Electrical Room floor is free of slip/trip/fall hazards.

Electrical Room baseboard are free of buildup of dirt.

Electrical Room floors are coated with a slip resistant surface.

Electrical Room floors are dry.

Electrical Room gloves and eye protection are available.

Electrical Room boxes and cabinets are labeled.

Electrical Room all doors on cabinets and boxes are original design.

Electrical sub panels have been infrared inspected within the last 2 years (Note date of last inspection)

Electrical Room has HIGH VOLTAGE signs posted.

Electrical Room equipment does not show signs of deterioration.

Electrical Room motor control doors / covers are closed and latched.

Electrical Room disconnect breaker arms function properly.

Electrical Room has restricted access. (Who generally has access).

Electrical Room has emergency lighting (Battery Operated or Generator)

Electrical Room has adequate ventilation for heat load.

Other Photographs

COMMENTS / RECOMMENDATIONS

ELECTRIAL SUB PANELS

Electrical boxes and cabinets are labeled.

Electrical boxes all doors on cabinets and boxes are original design.

Electrical sub panels are locked.

Electrical sub panels have been infrared inspected within the last 2 years (Note date of last inspection)

Other Photographs

COMMENTS / RECOMMENDATIONS

UTILITIES

Utilities are adequately marked

Utilities shutoffs are marked

Other Photographs

COMMENTS / RECOMMENDATIONS

Offices

OFFICES

Office door is free of damage and in good repair.

Office free of objectionable odors.

Office ceiling vents clean.

Office ventilation is working.

Office ceilings clean and free of stains and marks.

Office fire sprinkler heads and pipe clean of dust, paint or other obstructions.

Office has no evidence of high pile storage.

Office lighting functional.

Office light lenses clean and free of debris (insects, etc...).

Office lights bulbs all illuminate.

Office walls clean and free of spots and stains.

Office walls free of peeling paint and excessive damage.

Office window treatments clean and in good repair

Office window glass free of finger prints and spots

Office windows are free of moisture between panes of glass.

Office windows are free from drafts.

Office ledges, window sills and shelves are free of dust and debris.

Office window screens in good repair.

Office artwork and decorations on walls free of dust.

Office baseboard heating vents clean, in good repair and free of dust.

Office floors free of dirt, dust, litter including corners.

Office floor is free of slip/trip/fall hazards.

Office floors waxed, polished and free of marks.

Office baseboard are free of buildup of dirt and wax.

Office carpeting clean of dirt, dust and litter including corners.

Office carpeting is free of stains / odors.

Office furniture is in good repair.

Other Photographs

COMMENTS / RECOMMENDATIONS

Resident Rooms

List resident rooms selected for audit

RESIDENT ROOMS

Resident room door is free of damage and in good repair.

Resident room free of objectionable odors.

Resident room ceiling vents clean.

Resident room ventilation is working.

Resident room ceilings clean and free of stains and marks.

Resident room fire sprinkler heads and pipe clean of dust, paint or other obstructions.

No evidence of high pile storage.

Resident room lighting functional.

Resident room light lenses clean and free of debris (insects, etc...).

Resident room lights bulbs all illuminate.

Resident room over bed light operational and free of dust and obstructions.

Resident room night light operational.

Resident room privacy curtains clean and free of holes and stains.

Resident room walls clean and free of spots and stains.

Resident room walls free of peeling paint and excessive damage.

Resident room window treatments clean and in good repair

Resident room window glass free of finger prints and spots

Resident room windows are free of moisture between panes of glass.

Resident room windows are free from drafts.

Resident room ledges, window sills and shelves are free of dust and debris.

Resident room window screens in good repair.

Resident room nurse call cords clean, intact and functional.

Resident room telephone is available and works.

Resident room television and remote control are available and functioning.

Resident room artwork and decorations on walls free of dust.

Resident room mirror is free of debris and streaking.

Resident room sink is clean, free of soap and other buildup including any exposed piping.

Resident room is stocked with soap, paper towels and gloves.

Baseboard heating vents clean, in good repair and free of dust.

Resident room floors free of dirt, dust, litter including corners.

Resident room floor is free of slip/trip/fall hazards.

Resident room floors waxed, polished and free of marks.

Resident room baseboard are free of buildup of dirt and wax.

Resident room carpeting clean of dirt, dust and litter including corners.

Resident room carpeting is free of stains / odors.

Resident room furniture is in good repair.

Resident room bed and frame is clean.

Resident room over bed table clean including base and wheels.

Resident room oxygen and other storage is appropriate.

Resident room oxygen in wall has a regulator available.

Resident room IV, Tube Feeding stands clean including base and wheels.

Resident room is decorated and homelike.

Sharps containers are readily available, removed when 3/4 full and not accessible to Resident rooms

Resident personal care items are sanitized and properly stored (Basins, bed pans, urinals, etc...)

Other Photographs

COMMENTS / RECOMMENDATIONS

RESIDENT BATHROOMS

Bathroom door is free of damage and in good repair.

Bathroom free of objectionable odors.

Bathroom ceiling vents clean.

Bathroom ventilation is working.

Bathroom ceilings clean and free of stains and marks.

Bathroom fire sprinkler heads and pipe clean of dust, paint or other obstructions.

No evidence of high pile storage.

Bathroom lighting functional.

Bathroom light lenses clean and free of debris (insects, etc...).

Bathroom lights bulbs all illuminate.

Bathroom walls clean and free of spots and stains.

Bathroom walls free of peeling paint and excessive damage.

Bathroom EMERGENCY pull cords are operational and cords not shorter than 6" above floor.

Bathroom artwork and decorations on walls free of dust.

Bathroom mirror is free of debris and streaking.

Bathroom is stocked with soap, paper towels and toilet tissue.

Bathroom area is free of common bar soaps, shampoos, etc.

Bathroom is not over stocked with suppliers.

Bathroom sink is clean, free of soap and other buildup including any exposed piping.

Bathroom toilet is clean and free of stains.

Bathroom shower / tub is clean.

Bathroom grab bars for showers and toilets are present, clean and secure.

Bathroom is stocked with soap, paper towels and toilet tissue.

Bathroom Floor drains have grates covering piping.

Bathroom floors free of dirt, dust, litter including corners.

Bathroom floor is free of slip/trip/fall hazards.

Bathroom floors waxed, polished and free of marks.

Baseboard are free of buildup of dirt and wax.

Commode / shower chairs are clean, free of rust and in good repair.

Other Photographs

COMMENTS / RECOMMENDATIONS

Restrooms

RESTROOMS, PUBLIC / STAFF

Restroom door is free of damage and in good repair.

Restroom free of objectionable odors.

Restroom ceiling vents clean.

Restroom ventilation is working.

Restroom ceilings clean and free of stains and marks.

Restroom fire sprinkler heads and pipe clean of dust, paint or other obstructions.

Restroom has no evidence of high pile storage.

Restroom lighting functional.

Restroom light lenses clean and free of debris (insects, etc...).

Restroom lights bulbs all illuminate.

Restroom walls clean and free of spots and stains.

Restroom walls free of peeling paint and excessive damage.

Restroom EMERGENCY pull cords are operational and cords not shorter than 6" above floor.

Restroom artwork and decorations on walls free of dust.

Restroom mirror is free of debris and streaking.

Restroom is stocked with soap, paper towels and toilet tissue.

Restroom area is free of common bar soaps, shampoos, etc.

Restroom is not over stocked with suppliers.

Restroom sink is clean, free of soap and other buildup including any exposed piping.

Restroom toilet is clean and free of stains.

Restroom shower / tub is clean.

Restroom grab bars for showers and toilets are present, clean and secure.

Restroom is stocked with soap, paper towels and toilet tissue.

Restroom Floor drains have grates covering piping.

Restroom floors free of dirt, dust, litter including corners.

Restroom floor is free of slip/trip/fall hazards.

Restroom floors waxed, polished and free of marks.

Restroom baseboard are free of buildup of dirt and wax.

Other Photographs

COMMENTS / RECOMMENDATIONS

Salon / Barber Beauty

SALON / BARBER BEAUTY SHOP

Salon door is free of damage and in good repair.

Salon free of objectionable odors.

Salon ceiling vents clean.

Salon ventilation is working.

Salon ceilings clean and free of stains and marks.

Salon fire sprinkler heads and pipe clean of dust, paint or other obstructions.

Salon has no evidence of high pile storage.

Salon lighting functional.

Salon light lenses clean and free of debris (insects, etc...).

Salon lights bulbs all illuminate.

Salon walls clean and free of spots and stains.

Salon walls free of peeling paint and excessive damage.

Salon window treatments clean and in good repair.

Salon window glass free of finger prints and spots.

Salon windows are free of moisture between panes of glass.

Salon windows are free from drafts.

Salon ledges, window sills and shelves are free of dust and debris.

Salon window screens in good repair.

Salon nurse call cords clean, intact and functional.

Salon telephone is available and works.

Salon artwork and decorations on walls free of dust.

Salon mirror(s) are free of debris and streaking.

Salon hadwash sink is clean, free of soap and other buildup including any exposed piping.

Salon is stocked with soap, paper towels and gloves.

Salon hair wash sink is cleaned and disinfected after each resident use.

Salon baseboard heating vents clean, in good repair and free of dust.

Salon floors free of dirt, dust, litter including corners.

Salon floors are free of hair immediately after each haircut

Salon floor is free of slip/trip/fall hazards.

Salon floors waxed, polished and free of marks.

Salon baseboard are free of buildup of dirt and wax.

Salon furniture is in good repair.

Salon oxygen and other storage is appropriate.

Salon sharps containers are readily available, removed when 3/4 full and not accessible to residents.

Salon furniture is in good repair.

Salon furniture is clean.

Salon brushes, combs, clips, curlers are free of hair, cleaned and disinfected after each resident use.

Salon capes and towels are clean and stored when not in use.

Salon hair dryers are clean and free of hazards including cords.

Salon curling irons, flat irons and wax units are unplugged when not in use.

Salon equipment in not plugged in a way to exceed electrical capacity.

Salon chemicals are properly labeled and stored in a locked area.

Residents are not near heat generating appliances when receiving salon services.

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COMMENTS / RECOMMENDATIONS

Spa / Bathing Rooms

SPA

Spa entrance door is free of damage and in good repair.

Spa free of objectionable odors.

Spa ceiling vents clean.

Spa ventilation is working.

Spa ceilings clean and free of stains and marks

Spa fire sprinkler heads and pipe clean of dust, paint or other obstructions

Spa has no evidence of high pile storage

Spa lighting functional.

Spa light lenses clean and free of debris (insects, etc...)

Spa lights bulbs all illuminate

Spa walls clean and free of spots and stains

Spa walls free of peeling paint and excessive damage

Spa EMERGENCY pull cords are operational and cords not shorter than 6" above floor.

Spa artwork and decorations on walls free of dust

Spa mirror is free of debris and streaking.

Spa area is free of common bar soaps, shampoos, etc.

Spa Floor drains have grates covering piping.

Spa floors free of dirt, dust, litter including corners.

Spa floor is free of slip/trip/fall hazards.

Spa floors waxed, polished and free of marks.

Spa baseboard are free of buildup of dirt and wax.

Spa sharps containers are readily available, removed when 3/4 full and not accessible to residents

Spa shower chairs are disinfected after each use

Spa whirlpool tubs are cleaned of hair and soap debris. disinfected and cleaned after each use

Spa whirlpool tub disinfected and cleaned after each use

Spa bathing surfaces are non slip

Spa cleaning and disinfecting chemicals are properly labeled and stored in a locked area

Spa water temperatures are taken at least weekly and logged indicating within acceptable range

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COMMENTS / RECOMMENDATIONS

RESTROOM / SHOWER

Restroom door is free of damage and in good repair.

Restroom free of objectionable odors.

Restroom ceiling vents clean.

Restroom ventilation is working.

Restroom ceilings clean and free of stains and marks.

Restroom fire sprinkler heads and pipe clean of dust, paint or other obstructions.

Restroom has no evidence of high pile storage.

Restroom lighting functional.

Restroom light lenses clean and free of debris (insects, etc...).

Restroom lights bulbs all illuminate.

Restroom walls clean and free of spots and stains.

Restroom walls free of peeling paint and excessive damage.

Restroom EMERGENCY pull cords are operational and cords not shorter than 6" above floor.

Restroom artwork and decorations on walls free of dust.

Restroom mirror is free of debris and streaking.

Restroom is stocked with soap, paper towels and toilet tissue.

Restroom area is free of common bar soaps, shampoos, etc.

Restroom is not over stocked with suppliers.

Restroom sink is clean, free of soap and other buildup including any exposed piping.

Restroom toilet is clean and free of stains.

Restroom shower / tub is clean.

Restroom grab bars for showers and toilets are present, clean and secure.

Restroom is stocked with soap, paper towels and toilet tissue.

Restroom Floor drains have grates covering piping.

Restroom floors free of dirt, dust, litter including corners.

Restroom floor is free of slip/trip/fall hazards.

Restroom floors waxed, polished and free of marks.

Restroom baseboard are free of buildup of dirt and wax.

Restroom commode / shower chairs are clean, free of rust and in good repair.

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COMMENTS / RECOMMENDATIONS

Stairwells

STAIRWELLS

Stairwell door is free of damage and in good repair.

Stairwell free of objectionable odors.

Stairwell ceiling vents clean.

Stairwell ventilation is working.

Stairwell ceilings clean and free of stains and marks.

Stairwell fire sprinkler heads and pipe clean of dust, paint or other obstructions.

Stairwell lighting functional.

Stairwell light lenses clean and free of debris (insects, etc...).

Stairwell lights bulbs all illuminate.

Stairwell emergency lighting present and tested monthly and 90 minutes annually if battery operated

Stairwell walls clean and free of spots and stains.

Stairwell walls free of peeling paint and excessive damage.

Stairwell window glass free of finger prints and spots

Stairwell windows are free of moisture between panes of glass.

Stairwell windows are free from drafts.

Stairwell standard railings are on the open sides of all exposed stairways and stairwells?

Stairwell handrails are on at least one side of a closed stairway?

Stairwell liquid spills removed quickly and marked with wet floor signs as needed.

Stairwell stair treads have a reasonable slip-resistant construction with similar nosing.

Stairwell floors free of dirt, dust, litter including corners.

Stairwell floor is free of slip/trip/fall hazards.

Stairwell floors waxed, polished and free of marks.

Stairwell baseboard are free of buildup of dirt and wax.

Stairwell carpeting clean of dirt, dust and litter including corners.

Stairwell carpeting is free of stains / odors.

Stairwell no storage in stairwells or under stairwells.

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COMMENTS / RECOMMENDATIONS

Swimming Pool

SWIMMING POOL

EXTERIOR DOOR LOCKED / SECURE

MECHANICAL / CHEMICAL ROOM DOOR LOCKED

No Diving signs posted

Bather rules posted

Pool deck is free of obstructions

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COMMENTS / RECOMMENDATIONS

RESTROOM / CHANGING ROOM

Restroom door is free of damage and in good repair.

Restroom free of objectionable odors.

Restroom ceiling vents clean.

Restroom ventilation is working.

Restroom ceilings clean and free of stains and marks.

Restroom fire sprinkler heads and pipe clean of dust, paint or other obstructions.

Restroom has no evidence of high pile storage.

Restroom lighting functional.

Restroom light lenses clean and free of debris (insects, etc...).

Restroom lights bulbs all illuminate.

Restroom walls clean and free of spots and stains.

Restroom walls free of peeling paint and excessive damage.

Restroom EMERGENCY pull cords are operational and cords not shorter than 6" above floor.

Restroom artwork and decorations on walls free of dust.

Restroom mirror is free of debris and streaking.

Restroom is stocked with soap, paper towels and toilet tissue.

Restroom area is free of common bar soaps, shampoos, etc.

Restroom is not over stocked with suppliers.

Restroom sink is clean, free of soap and other buildup including any exposed piping.

Restroom toilet is clean and free of stains.

Restroom shower / tub is clean.

Restroom grab bars for showers and toilets are present, clean and secure.

Restroom is stocked with soap, paper towels and toilet tissue.

Restroom Floor drains have grates covering piping.

Restroom floors free of dirt, dust, litter including corners.

Restroom floor is free of slip/trip/fall hazards.

Restroom floors waxed, polished and free of marks.

Baseboard are free of buildup of dirt and wax.

Commode / shower chairs are clean, free of rust and in good repair.

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COMMENTS / RECOMMENDATIONS

POOL CHEMISTRY RECORDS

Bound log present / used

Chlorine / pH readings daily

Free Chlorine Residual 1.0 to 3.0 [Optimal 2.5 to 3.0]

Combined Chlorine - Maximum 0.2

pH - 7.2 to 7.8 [Optimal 7.4 to 7.5]

Total alkalinity 80 to 100 ppm

Calcium hardness 200 - 400 ppm

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COMMENTS / RECOMMENDATIONS

OTHER RECORDED INFORMATION

Date and times of last 3 tests

Bather load

Water clarity / water temperature

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COMMENTS / RECOMMENDATIONS

SAFETY EQUIPMENT

Telephone available

Emergency numbers posted at telephone

Assist pole / life hook

Throw able rescue tube

Full spine board with ties/straps

First Aid Kit complete

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COMMENTS / RECOMMENDATIONS

Utility Room, Clean

UTILITY ROOM, CLEAN

Utility room, clean door is free of damage and in good repair.

Utility room, clean free of objectionable odors.

Utility room, clean ceiling vents clean.

Utility room, clean ventilation is working.

Utility room, clean ceilings clean and free of stains and marks.

Utility room, clean fire sprinkler heads and pipe clean of dust, paint or other obstructions.

Utility room, has no evidence of high pile storage.

Utility room, clean lighting functional.

Utility room, clean light lenses clean and free of debris (insects, etc...).

Utility room, clean lights bulbs all illuminate.

Utility room, clean walls clean and free of spots and stains.

Utility room, clean walls free of peeling paint and excessive damage.

Utility room, clean ledges, window sills and shelves are free of dust and debris.

Utility room, clean hadwash sink is clean, free of soap and other buildup including any exposed piping.

Utility room, clean sinks are clean

Utility room, clean no storage under sink cabinets

Utility room, clean is stocked with soap, paper towels and gloves.

Utility room, clean baseboard and/or heating vents clean, in good repair and free of dust.

Utility room, clean floors free of dirt, dust, litter including corners.

Utility room, clean floor is free of slip/trip/fall hazards.

Utility room, clean floors waxed, polished and free of marks.

Utility room, clean baseboard are free of buildup of dirt and wax.

Utility room, clean sharps containers are readily available, removed when 3/4 full and not accessible to residents.

Utility room, clean chemicals are properly labeled and stored in a locked area.

Other Photographs

COMMENTS / RECOMMENDATIONS

Utility Room, Soiled

UTILITY ROOM, SOILED

Utility room, soiled door signage for bio-hazard.

Utility room, soiled door is free of damage and in good repair.

Utility room, soiled free of objectionable odors.

Utility room, soiled ceiling vents clean.

Utility room, soiled ventilation is working.

Utility room, soiled ceilings clean and free of stains and marks.

Utility room, soiled fire sprinkler heads and pipe clean of dust, paint or other obstructions.

Utility room, has no evidence of high pile storage.

Utility room, soiled lighting functional.

Utility room, soiled light lenses clean and free of debris (insects, etc...).

Utility room, soiled lights bulbs all illuminate.

Utility room, soiled walls clean and free of spots and stains.

Utility room, soiled walls free of peeling paint and excessive damage.

Utility room, soiled ledges, window sills and shelves are free of dust and debris.

Utility room, soiled hand wash sink is clean, free of soap and other buildup including any exposed piping.

Utility room, soiled hopper sink is clean and in working order, hoses hung properly.

Utility room, soiled no storage under sink cabinets.

Utility room, soiled is stocked with soap, paper towels and gloves.

Utility room, soiled baseboard and/or heating vents clean, in good repair and free of dust.

Utility room, soiled floors free of dirt, dust, litter including corners.

Utility room, soiled floor is free of slip/trip/fall hazards.

Utility room, soiled floors waxed, polished and free of marks.

Utility room, soiled baseboard are free of buildup of dirt and wax.

Utility room, soiled specimen refrigerator marked for bio-hazard and used only for specimens.

Utility room, soiled sharps containers are readily available, removed when 3/4 full and not accessible to residents.

Utility room, soiled trash / garbage (non contaminated) is not placed in bio-hazard container.

Utility room, soiled appropriate style emergency eyewash station is available

Utility room, soiled disinfectant is stocked and available.

Utility room, soiled gloves, gowns and eye protection are available.

Utility room, soiled bio-hazard bags are placed in appropriate location for disposal.

Utility room, soiled chemicals are properly labeled and stored in a locked area.

Utility room, soiled linen barrels/hampers remain covered and emptied when necessary.

Utility room, soiled linen barrels cleaned per facility schedule (Identify schedule of this event).

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COMMENTS / RECOMMENDATIONS

Vestibule

VESTIBULE

Vestibule door is free of damage and in good repair.

Vestibule free of objectionable odors.

Vestibule ceiling vents clean.

Vestibule ventilation is working.

Vestibule ceilings clean and free of stains and marks.

Vestibule fire sprinkler heads and pipe clean of dust, paint or other obstructions.

Vestibule lighting functional.

Vestibule light lenses clean and free of debris (insects, etc...).

Vestibule lights bulbs all illuminate.

Vestibule walls clean and free of spots and stains.

Vestibule walls free of peeling paint and excessive damage.

Vestibule window treatments clean and in good repair

Vestibule window glass free of finger prints and spots

Vestibule windows are free of moisture between panes of glass.

Vestibule windows are free from drafts.

Vestibule ledges, window sills and shelves are free of dust and debris.

Vestibule window screens in good repair.

Vestibule telephone is available and works.

Vestibule artwork and decorations on walls free of dust.

Vestibule baseboard heating vents clean, in good repair and free of dust.

Vestibule floors free of dirt, dust, litter including corners.

Vestibule floor is free of slip/trip/fall hazards.

Vestibule floors waxed, polished and free of marks.

Vestibule baseboard are free of buildup of dirt and wax.

Vestibule carpeting clean of dirt, dust and litter including corners.

Vestibule carpeting is free of stains / odors.

Vestibule furniture is in good repair.

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COMMENTS / RECOMMENDATIONS

EOC Policies, Procedures and Processes

HAZARDOUS MATERIALS / CHEMICAL SAFETY

If the building was built prior to 1980, has a survey been conducted to identify the presence of Asbestos Containing Materials (ACM).

Written Hazardous Communication (HAZCOM) Plan is readily available

HAZCOM plan has a list of chemicals used at the community

SDS Available to all staff for all chemicals

List high hazard chemicals pH <2 Or >9

All containers labeled correctly?

Unused substances disposed of?

Do special storage conditions apply? (Flammable, caustic, corrosive)

Are special storage conditions applied?

Staff trained and in serviced in the use of hazardous substances?

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COMMENTS / RECOMMENDATIONS

PERSONAL PROTECTIVE EQUIPMENT.

Has a survey of the workplace been conducted to identified tasks and jobs that require personal protective equipment (PPE)?

Have potential hazards been identified associated with each task using the Personal Protective Equipment Survey and Analysis Checklist for guidance?

Are required PPE identified on the PPE Hazard Assessment Certification Form?

Has the PPE Hazard Assessment Certification Form been completed and signed.

Copies of the PPE Hazard Assessment Certification Forms are kept with the Hazard Communication Program?

Are PPE (Personal Protective Equipment) readily available when necessary?

Does staff use PPE when appropriate? (Including standard precautions)

Are eye wash stations and emergency showers readily available? (Locations)

Are portable eye wash stations on housekeeping carts

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COMMENTS / RECOMMENDATIONS

PROCESS - Housekeeping

EVS staff knock before entering resident spaces where privacy is expected

EVS staff dust mops entire area before mopping

EVS staff wet mop the entire floor

Mop water is changed every 3 rooms when not using micro fiber mop?

Mop water is changed after every contact precaution room?

Microfiber mopping is used?

Microfiber mop pad changed after ever room

Wet floor signs used as appropriate?

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COMMENTS / RECOMMENDATIONS

EQUIPMENT - Housekeeping

Equipment is clean and maintained in serviceable condition?

COMMENTS / RECOMMENDATIONS

SCHEDULES - Housekeeping

Number of Housekeeping FTE

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COMMENTS / RECOMMENDATIONS

Exit Conference

EXIT CONFERENCE and SIGNATURES
Other Photographs

COMMENTS / RECOMMENDATIONS

Date and time the audit was concluded and exit conference held
NAME and SIGNATURE OF COMMUNITY REPRESENTATIVE
NAME and SIGNATURE OF CHE/TSLC REPRESENTATIVE
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.