Free Nursing Home Infection Control Checklist Form

Please complete this form to verify adherence to our infection control practices.

Resident Information

Infection Control Procedures

Please review each item and check the box to confirm compliance or indicate if action is needed:

Hand Hygiene

• Staff and residents wash hands thoroughly with soap and water before meals, after bathroom use, and as necessary.

• Hand sanitizers are available in common areas and near high-contact surfaces.

Personal Protective Equipment (PPE)

• Staff wear appropriate PPE (e.g., gloves, masks, gowns) as needed, especially during personal care.

• PPE supplies are adequately stocked and readily accessible.

Resident Health Monitoring

• Regular temperature checks and symptom screenings are conducted for all residents.

• Symptomatic residents are isolated immediately, and medical care is sought as needed.

Cleaning and Disinfection

• High-touch surfaces (e.g., doorknobs, handrails) are cleaned and disinfected multiple times daily.

• Resident rooms, bathrooms, and common areas are thoroughly cleaned according to infection control standards.

Waste Disposal

• Waste bins with lids are available for disposing of used PPE, tissues, and other potentially contaminated materials.

• Waste is removed and disposed of safely and regularly.

Linen and Laundry Handling

• Used linens are placed in designated bags immediately after use and handled with gloves.

• Laundry is washed at appropriate temperatures to kill bacteria and viruses.

Visitor Management

• Visitors are screened for symptoms upon entry and must follow infection control guidelines (e.g., wearing masks).

• Visitor numbers are monitored to prevent overcrowding, and hand sanitizers are provided at entry points.

Food Safety and Dining Area Protocols

• Dining areas are sanitized before and after meals, and food is handled with gloves.

• Residents are encouraged to follow hand hygiene before eating, and communal items (e.g., salt shakers) are minimized.

Ventilation and Air Quality

• Windows or HVAC systems are used to ensure proper ventilation in common areas and rooms.

• Air filters are maintained and changed regularly to support air quality.

Emergency Protocols for Outbreaks

• A response plan is in place for infection outbreaks, including isolation and notification of public health authorities.

• Staff are trained on emergency infection control protocols and procedures.

Acknowledgment and Signature

• By signing below, I confirm that I have reviewed the infection control checklist and verified compliance with each item to the best of my knowledge.

Resident Signature (if applicable)

Name:

Date:

Assessor Signature

Name:

Date:

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