Facility Self-Assessment (Mock Survey) Tool - Nursing Home Help

FIRST IMPRESSIONS CHECKLIST
Item to be Inspected Met Not
met
Facility signage visible, well lit, clean, sturdy and in good repair.
Parking lot is clean, striped and well lit.
Handicap stall is present and clearly marked with signage.
Lawn /grounds are well kept, neat in appearance and wellmanicured
without trash or clutter. Shrubbery is trimmed and
flowerbeds weeded.
Lawn furniture is clean, in good repair and adequate.
Lawn hoses are stored and do not pose a tripping hazard.
Entrance landscaped seasonally. Out of season decorations removed
timely. Outside potted plants alive & well groomed.
Entrances clean, well lit and without clutter.
Front door clean, in good repair with weather stripping secure.
Sidewalk poses no tripping hazards and is in good repair.
Receptacle for cigarettes available at entrance and is emptied
regularly.
Lobby neatly organized, lighting appropriate (all bulbs working),
low noise levels (including overhead paging).
Greeted upon entrance by a staff member.
Inside “potted” plants alive / well groomed.
Staff members appropriately dressed with name badge.
Visible office spaces neatly organized and clutter free.
All areas odor free.
Public restrooms clean and comfortable.
Public posting information is well organized and easily accessible
(i.e., State Survey Results, other required info by law).
Facility has a feel of comfort and is not institutional.
Hallways are free of obstruction.
Dining areas are clean, neat and offer a home like appeal.
Resident smoking area clean of cigarette butts and other trash.
Available ashtrays and trash cans cleaned/dumped at least daily if
not more often. Patio furniture clean, good repair and adequate.
Patio poses no tripping hazards and is in good repair.
Staff smoking area clean of cigarette butts and other trash.
Available ashtrays and trash cans cleaned/dumped at least daily if
not more often.
Area around dumpsters are clean and clutter free. Lids on
dumpsters are closed.
Laundry and Dietary outside areas clean and uncluttered.
Surrounding area outside storage buildings clean and uncluttered.
Gutters and down spouts securely attached and function properly.
Siding/brick is in good repair, not chipped, cracked or broken nor is
paint chipped.
Window panes are in good condition without chipped paint and no
broken windows.
Window screens are clean, not torn and in good repair.
Corrective Action
Date
corrected
5.45