Title Page
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Prepared by
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Location
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Date
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Room Number
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Is the room free of any trip hazards?
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Is the floor dry & free of spills (or is a wet floor sign visible)?
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Does the door/s open freely?
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Is the lighting adequate?
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Do the windows open freely?
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Is the fly screen intact & free of any holes?
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Are there any electrical items in the room?
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Is the equipment tagged?
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Is the tag in date?
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Is there furniture in the room?
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List of furniture in the room
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Are these items in good condition?
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Does the resident call bell work?
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Is the call bell within reach of the bed?
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Does this room have a bathroom?
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Is the floor free of damage and trip hazards?
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Are all the fixtures in good working order?
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Is the exhaust fan working and free of blockages?
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Are the grab rails in good condition & secure?
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Are there any other hazards to report?
