QUALITY OF CARE ROUNDS - Nursing Home Help

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Facility Inspection ReportPossibleA. Entrance/Lobby/Sitting RoomSCOREB. Corridors and WallsScoreWalkway free of litter? 6 Corridors clean, waxed, polished and/orcorridor carpets clean, free of spots?Cigarette urns clean and free of trash? 6 All decoration on walls free of dust? 3Walkway free of cigarette butts? 6 Baseboards clean and polished? 3Walk off mats clean and in proper 6 Ceiling lights clean and clear? 3location?Entrance glass free of finger prints? 6 Ceiling vents clean? 3Lobby is odor free? 6 Corners neat and clean? 3Corners clean? 6 Fire extinguishers clean? 3Floors (carpets) clean of dirt, dust, litter? 6 Floor is free of marks left by wheelchairs, 3Floors clean, waxed, polished and/orcarpet clean, fresh where applicable?etc.?25 Corridors free of odors? 3Lights clean and clear? 5 Handrails clean and free of debris? 3Baseboards clean? 5 Kick plates shined? 3Furniture clean and arranged neatly? 5 Walls clean and free of smudges? 3Visible ledges free of dust? 6 Wet floor sigs in place when mopping floor? 3Plants and ornaments clean? 5 Walls painted/papered and free or damage? 3Vents clean? 5Public rest rooms clean, free of trash? 4Total 108 Total 66PossibleScore30SCOREC. EquipmentPossibleScoreSCORED. DietaryBuffer clean? 3 Appliances clean & in running order? 3Vacuums clean? 3 Range hood clean & in running order? 3All equipment in running order? 3 Counters & Cabinets clean? 3Mop buckets clean? 3 Floors/Mats clean? 3Chemicals stored appropriately? 3 Walls and backsplash clean? 3Correct labels in use? 3 Food labeled correctly? 3No food or drink on Housekeeping cart? 3 Barrels empty clean & lined appropriately? 3Housekeeping carts clean and orderly? 3 Pantry clean and orderly? 3Closet free of all unnecessary items? 3 Storage free of all unnecessary items? 3Floor sink and drain clean? 3 Floor sink and drain clean? 3Janitor closet clean and orderly 3 Coolers clean and orderly? 3Mops clean and stored appropriately? 3 Freezers clean and orderly? 3Material Safety Data Sheets (MSDS)available?3 Chemicals stored appropriately? 3Maintenance Room clean and orderly? 3 Dishwasher water temp adequate? 3Total 42 42PossibleScoreSCORENotes ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4.59
Facility Inspection ReportE. Resident RoomsPossibleScoreRoom #PossibleScoreRoom#Is room odor free? 6 6 6Is toilet bowel clean? 4 4 4Mirrors shined? 4 4 4Pipes clean and free of dust and dirt? 4 4 4Sink free of soap buildup (top & bottom)? 4 4 4Bathroom floor clean? 4 4 4Cubicle curtains, drapery, valances, clean? 4 4 4Floor clean or dirt, dust and litter? 10 10 10Floor finished with wax? 10 10 10Baseboards clean? 4 4 4Furniture clean? 4 4 4Ledges free of dust? 4 4 4Lights free of dust? 4 4 4Vents clean? 4 4 4Walls clean and free of spots? 4 4 4Waste basket clean and free of litter? 4 4 4Windows clean and free of finger prints? 4 4 4Total 82 82 82PossibleScoreRoom#F. Departments/OfficesPossibleScoreRoom/OfficePossibleScoreRoom/OfficeBaseboards clean? 2 2 2Cabinet and counters clean? 2 2 2Ceiling lights clean and clear? 2 2 2Corners neat and clean? 2 2 2Floor clean of dirt, dust and litter? 2 2 2Floor waxed or carpet clean? 2 2 2Furniture cleaned? 2 2 2Ledges free of dust? 2 2 2Nothing stored on floor? 2 2 2Vents and registers clean? 2 2 2Walls clean and free of smudges? 2 2 2Waste baskets clean and freshly lined? 2 2 2Window blinds free of dust? 2 2 2Windows clean and free of smudges? 2 2 2Waste basket clean and free of litter?Windows clean and free of finger prints?Total 31 31 31PossibleScoreRoom/OfficeNotes ______________________________________________________________________________________________________________________________________________________________________________4.60
Page 1 and 2:
Quality ofCare RoundsUnlike the Moc
Page 4 and 5:
RR SS PE IC EP F-Tag Observations S
Page 6 and 7:
Page 8 and 9:
Page 10 and 11: RR SS PE IC EP F-Tag Observations S
Page 12 and 13: Exit lightsRESIDENT ROOMS “U”
Page 14 and 15: OTHER AREAS “U” “S” COMMENT
Page 16 and 17: Thawing foods put in refrigerator c
Page 18 and 19: SS follows upon discharge needs of
Page 20 and 21: - re-feeding/walk and dine- bowel/b
Page 22 and 23: Pumps/poles and equipment cleanWEIG
Page 24 and 25: No expired medications on handSharp
Page 26 and 27: Medical Director review of all repo
Page 28 and 29: MDS/CARE PLAN TRACKING FORMName: Ro
Page 30 and 31: HOT HOLDINGHot holding unit / steam
Page 32 and 33: Step ladders are sturdy and in good
Page 34 and 35: Yes No Buckets, tubs and pans are i
Page 36 and 37: Yes No Cleaning schedules posted an
Page 38 and 39: INFECTION CONTROL AND SAFETY SURVEI
Page 40 and 41: Yes No Electric cords for lights, r
Page 52 and 53: Yes No All wandering bracelets are
Page 54 and 55: Extended menusavailableDumpster lid
Page 56 and 57: Housekeeping Carts, Equipment, and
Page 58 and 59: Facility InspectionFacility _______
Page 62 and 63: Facility Inspection ReportAREAScore
Page 64 and 65: Figure A.7Survey tag assignment (co
Page 72: Figure A.7Survey tag assignment (co
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QUALITY OF CARE ROUNDS - Nursing Home Help

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