Facility Self-Assessment (Mock Survey) Tool - Nursing Home Help
Facility Self-Assessment (Mock Survey) Tool - Nursing Home Help
Facility Self-Assessment (Mock Survey) Tool - Nursing Home Help
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MONTHLY SANITATION/INFECTION CONTROL REVIEW<br />
DATE: FACILITY: REVIEWER:<br />
AREAS OF OBSERVATION POINTS COMMENTS<br />
1. FIRST IMPRESSION of dietary cleanliness from dietary<br />
entrance is favorable.<br />
8 4 0<br />
2. Floor is clear of trash and food particles. 4 2 0<br />
3. Walls are free of splatters, damage, peeling paint, paper<br />
clutter, etc. Papers are all in covers on clean bulletin board(s).<br />
4 2 0<br />
4. Ceiling is in good repair and appears clean, with clean,<br />
unbroken light fixtures - all bulbs working/bulbs covered.<br />
4 2 0<br />
5. Hood is free of grease, operational, lights work, extinguisher<br />
nozzles free of grease/dust, filters clean.<br />
4 2 0<br />
6. In dry storage, food is off floor by 6”, on sanitizable shelves,<br />
18” from ceiling, all food is in enclosed clean containers if<br />
opened. Food is neatly arranged/dated and FIFO. No empty<br />
4 2 0<br />
boxes and damaged products are grouped for return.<br />
7. In refrigerated/freezer storage, food is neatly arranged on<br />
clean shelving. Thermometers register less than 41 degrees F. 4 2 0<br />
or 0 degrees F. for freezer.<br />
8. All opened food is labeled/dated, and covered. 4 2 0<br />
9. There are no smudges, fingerprints, dried food particles on<br />
refrig./freezer outside surfaces.<br />
2 1 0<br />
10. Nonfood and chemicals are stored away from food. 3 1 0<br />
11. Walk-in, floors dry, clean fans, covered lighting. 2 1 0<br />
12. Inside and outside of all cooking equipment is clean. 4 2 0<br />
13. All work surfaces, under shelves and legs are free of<br />
food/dirt/dust/grease build-up.<br />
3 1 0<br />
14. All surfaces are free of rust. 2 1 0<br />
15. Prep. equipment/dishes/utensils are effectively sanitized and<br />
properly stored.<br />
4 2 0<br />
16. Food transport prevents contamination. 3 1 0<br />
17. Sewage and plumbing meet state or local law. 3 1 0<br />
18. All refuse containers are covered/clean/adequate. 3 1 0<br />
19. Frozen foods are thawed properly. 3 1 0<br />
20. Safe water source with sufficient hot/cold water under<br />
pressure.<br />
3 1 0<br />
21. The can opener is clean/blade not badly worn 3 1 0<br />
22. There are sufficient cleaning cloths in good condition. 2 1 0<br />
23. The pot/pan sink is used properly. 3 1 0<br />
24. Hairnets are on/dress appropriate/no nail polish. 3 1 0<br />
25. All carts are clean – including wheels. 2 1 0<br />
26. Manager’s office is free of clutter/organized. 3 1 0<br />
27. Only NSF approved food storage containers are used for<br />
leftovers, opened items, etc.<br />
3 1 0<br />
28. Slicer and mixer bowl are covered when unused. 2 1 0<br />
29. There is no sign of pest infestation. 3 1 0<br />
30. All equipment is working properly. 3 1 0<br />
31. Mops are hung-up, brooms, etc. stored properly. 2 1 0<br />
CIRCLE POINTS ACCORDING TO FINDINGS. COMMENT ON ALL COLUMN 3 FINDINGS.<br />
Column 1 = Excellent; Column 2 = Improvements needed; Column 3 = Unacceptable<br />
RECORD THE SUM OF ALL POINTS CIRCLED _______________ (THERE ARE 100 POSSIBLE POINTS.)<br />
A SCORE OF LESS THAN 75 REQUIRES FOLLOW-UP BY ADMINISTRATOR & MANAGER WITHIN 7 DAYS.<br />
5.84
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