Run Mock Annual Survey Audit for Nursing Homes — Free

Survey Scope and Facility Readiness

Survey scope defined and units selected for walkthrough

Yes No N/A

Current census, acuity, and resident sample list available

Yes No N/A

Required policies, QAPI records, and recent plans of correction available for review

Yes No N/A

Administrator, DON, and department leads notified and available for interview

Yes No N/A

Entrance conference materials organized and accessible

Yes No N/A

Resident Rights, Care Planning, and Clinical Documentation

Resident rights postings visible and current in common areas

Yes No N/A

Care plans are individualized, current, and reflect assessed needs and interventions

Yes No N/A

MDS, assessments, and physician orders are consistent with the medical record

Yes No N/A

Behavioral interventions and psychotropic medication monitoring are documented when applicable

Yes No N/A

Pain assessment and reassessment documentation present for residents with pain

Yes No N/A

Weight loss, hydration, and nutrition risk triggers have documented interventions

Yes No N/A

Falls, pressure injuries, and other adverse events have timely investigation and follow-up

Yes No N/A

Resident grievances and complaint resolution documentation is complete

Yes No N/A

Infection Prevention and Control

Hand hygiene supplies are available at point of care critical (required)

Yes No N/A

Staff demonstrate correct PPE selection and donning/doffing for isolation precautions critical (required)

Yes No N/A

Isolation signage is posted and matches resident precautions

Yes No N/A

Cleaning and disinfection logs are current for shared equipment and high-touch surfaces

Yes No N/A

Medication storage and treatment areas are clean, organized, and free of contamination risk

Yes No N/A

Outbreak response supplies and escalation contacts are available

Yes No N/A

Staff vaccination, training, and exposure follow-up records are current where required

Yes No N/A

Life Safety, Environment, and Emergency Preparedness

Exits, corridors, and exit access are unobstructed and properly marked critical (required)

Yes No N/A

Fire doors close and latch properly when tested critical (required)

Yes No N/A

Fire extinguishers are accessible, mounted, and within inspection date critical (required)

Yes No N/A

Emergency lighting and exit signage are operational critical (required)

Yes No N/A

Oxygen storage, electrical cords, and other hazards are managed safely

Yes No N/A

Emergency supplies, generator readiness, and disaster procedures are documented and accessible

Yes No N/A

Housekeeping and maintenance issues do not create trip, slip, or infection hazards

Yes No N/A

Staffing, Training, and Competency

Posted staffing schedule matches actual coverage for the survey period

Yes No N/A

Required annual training is current for direct care and support staff

Yes No N/A

Competency validation completed for high-risk tasks such as transfers, wound care, and medication assistance

Yes No N/A

Agency or float staff orientation and supervision are documented

Yes No N/A

Staff can describe escalation pathways for resident change in condition and emergencies

Yes No N/A

Findings, Corrective Actions, and Sign-Off

Likely citations or deficiencies identified and categorized by severity

Note (optional)

Corrective action plan documented for each failed item

Yes No N/A

Responsible owner and due date assigned for each corrective action

Yes No N/A

Follow-up verification method defined for each corrective action

Yes No N/A

Inspector summary and leadership sign-off completed

Note (optional)

Get your results

Enter your email — we'll send you a PDF of your filled-out template, plus the occasional MangoScoop newsletter (templates, workflow tips, product updates). Unsubscribe anytime — link is in every email.

Email (required)

Your name (optional)

Run: Mock Annual Survey Audit for Nursing Homes

Survey Scope and Facility Readiness

Resident Rights, Care Planning, and Clinical Documentation

Infection Prevention and Control

Life Safety, Environment, and Emergency Preparedness

Staffing, Training, and Competency

Findings, Corrective Actions, and Sign-Off

Get your results