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

DIETARY OBSERVATIONS
1x per month until survey window: then weekly
Place a check under the Yes or No column and N/A if practice not observed Yes No N/A
GENERAL OBSERVATIONS
Proper uniform per facility policy
Clean apron
Closed toed shoes
Minimal Jewelry (watch, wedding ring, stud earrings)
Hair restraints covering ALL hair (facial restraint if needed)
Fingernails short and clean
Visible wounds gloved at all times
No eating, drinking or chewing gum
Name tag worn
MEAL PREPARATION OBSERVATIONS
Hands washed before beginning meal preparation
Hands washed and/or gloves changed when soiled
Gloves worn when handling ready to eat foods or tongs used (i.e. potato chips, cookies, etc.)
Fruits & vegetables (not heated.. carrot sticks, celery, bananas, etc.)
Bread/bread products
Non-Rethermalized foods (food that won’t be reheated, i.e. chicken salad, chief salad)
Utensils used when ungloved
STEAM TABLE/SERVING LINE OBSERVATIONS
Hands washed before beginning meal service
Utensils/dedicated gloved hand used appropriately
Hands washed before gloves applied
Hands washed and/gloves changed when contaminated
Changing tasks (refrigerator, dishwasher, trash can) Sneezing
or coughing
Touching body or someone else
Touching unclean equipment or work surface
Plates handled by edges only
Bowls, cups, glasses handled by outside only
Second helpings served on new plate, bowl, etc.
Meal ticket/card available and used for each resident
Appropriate scoops used
PUREED MEAL OBSERVATION
Recipe available for meal being served
Recipe followed:
Correct Ingredients? Accurate measurements?
Finished product correct consistency?
If not, appropriate corrective action taken? (i.e. change recipe and have R.D. approve)
Reheated and/or cooled to appropriate temperatures
Date: __________
Meal observed (circle one): Breakfast Noon Evening
Observation by: _________________________________
Reviewed by: __________________________________
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