Nursing Home Audit Checklist Form
Use this Nursing Home Audit Checklist Form to assess facility standards and ensure compliance during your audit.
Auditor Name
*
First Name
Last Name
Date of Audit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Facility Name
*
Cleanliness of Common Areas
*
Excellent
Good
Fair
Poor
Safety Compliance (e.g., handrails, emergency exits)
*
Compliant
Partially Compliant
Non-Compliant
Staff Presence and Attentiveness
*
Excellent
Good
Fair
Poor
Medication Storage and Security
*
Secure and Organized
Needs Improvement
Non-Compliant
Resident Room Conditions
*
Excellent
Good
Fair
Poor
Emergency Preparedness (e.g., fire drills, evacuation plans)
*
Fully Prepared
Partially Prepared
Unprepared
General Comments or Observations
Submit Audit
Should be Empty: