Section 1: Clean Ledges And Sills
1. 1. Are the 8-sided fold methodology and disposable or damp green microfiber cloth used as per facility practices?
Yes
No
N/A
2. 2. Is the cloth wetted using the dip and wring, pour method, or charging bucket as directed by the supervisor?
Yes
No
N/A
3. 3. Is a damp cloth used to clean all ledges and sills while moving around the room?
Yes
No
N/A
4. 4. Is cleaning performed from high to low and in the same direction until all ledges and window sills are cleaned?
Yes
No
N/A
Section 2: Empty And Line Waste Receptacle
1. 1. Are sharp objects like hypodermic needles carefully avoided, and is reaching into the receptacle avoided?
Yes
No
N/A
2. 2. Is the liner bag fully closed before removal from the container, and is it placed in the appropriate collection bin?
Yes
No
N/A
3. 3. Is the container wiped down with an EPA-approved disinfectant, including all critical touch areas, and are the foot pedal, interior lid, exterior lid, and retainer bands disinfected?
Yes
No
N/A
4. 4. Is a new liner bag inserted into the container?
Yes
No
N/A
Section 3: Clean Bed And Footboard
1. 1. Is a damp, unused green microfiber cloth used for cleaning?
Yes
No
N/A
2. 2. Are the side rails, bedframe, and footboard cleaned, and is the mattress wiped down if the resident is not present?
Yes
No
N/A
Section 4: Clean Furniture And Furnishings
1. 1. Is a damp, unused green microfiber cloth used for cleaning?
Yes
No
N/A
2. 2. Is the over-bed table cleaned thoroughly from upper to lower surfaces
Yes
No
N/A
3. 3. Are the table’s surface, pedestal, base, and casters cleaned?
Yes
No
N/A
4. 4. Are the chairs damp-dusted, including the seat back, legs, and rungs?
Yes
No
N/A
5. 5. Are the over-the-bed lamp reflector, hood, and other wall fixtures damp-wiped as directed?
Yes
No
N/A
Section 5: Spot Clean Walls
1. 1. Are walls only cleaned if visually soiled?
Yes
No
N/A
2. 2. Is a damp, unused green microfiber cloth used for cleaning?
Yes
No
N/A
3. 3. Are wall mirrors and hangings, like pictures and signs, damp-dusted while moving around the unit?
Yes
No
N/A
4. 4. Are high-touch areas, such as around door sills, given particular attention?
Yes
No
N/A
Section 6: Clean Hardware
1. 1. Is a damp, unused green microfiber cloth used for cleaning hardware?
Yes
No
N/A
2. 2. Is the doorway hardware, including the doorknob, cleaned to avoid contamination?
Yes
No
N/A
3. 3. Is the kick plate cleaned with stainless steel cleaner?
Yes
No
N/A
Section 7: Disinfect Toilet Bowl
1. 1. Is a small quantity of bowl cleaner poured into the toilet bowl water?
Yes
No
N/A
2. 2. Is the bowl brush dipped into the toilet bowl water mixed with bowl cleaner and used to clean all inside surfaces of the bowl, including under the rim?
Yes
No
N/A
3. 3. Is the bowl cleaner allowed to stand in the bowl while completing other bathroom cleaning tasks to ensure proper dwell time?
Yes
No
N/A
Section 8: Perform High Dusting
1. 1. Is high dusting visually checked and performed if necessary?
Yes
No
N/A
2. 2. Is a damp duster used on the doorframe, door hinges, ceiling vents, lights, and tops of mirrors if needed?
Yes
No
N/A
Section 9: Clean Sink And Counter
1. 1. Is a damp, unused yellow microfiber cloth used for general cleaning?
Yes
No
N/A
2. 2. Is a damp blue microfiber glass cleaning cloth used for bright surfaces?
Yes
No
N/A
3. 3. Is the top of the sink and bowl wiped with the yellow cloth?
Yes
No
N/A
4. 4. Are the counter front and inside sink doors cleaned with the damp yellow cloth?
Yes
No
N/A
5. 5. Are the faucet handles and metal fixtures wiped and polished with the blue glass cloth?
Yes
No
N/A
6. 6. Are the piping and all exposed surfaces of the entire unit cleaned?
Yes
No
N/A
Section 10: Clean Toilet Surface
1. 1. Is a damp, yellow microfiber bathroom cloth used for cleaning?
Yes
No
N/A
2. 2. Are the piping and flush handle of the toilet cleaned and polished?
Yes
No
N/A
3. 3. Is the seat, top, front, and behind the bowl wiped clean?
Yes
No
N/A
4. 4. Is the yellow microfiber cloth placed in the dirty linen bag and not reused on other surfaces?
Yes
No
N/A
Section 11: Clean Shower And Tub
1. 1. Is a damp microfiber pad used with a spray cleaning solution applied to the tile, starting at the top and working to the bottom?
Yes
No
N/A
2. 2. Are the shower walls cleaned from top to bottom, finishing at the drain?
Yes
No
N/A
3. 3. Are the showerhead, faucet handles, and other fixtures wiped clean with a damp yellow microfiber cloth?
Yes
No
N/A
4. 4. Are the shower rod, handrails, and shower curtains wiped with the yellow cloth to ensure all areas are cleaned?
Yes
No
N/A
Section 12: Clean Mirrors
1. 1. Is a damp blue microfiber glass cleaning cloth used?
Yes
No
N/A
2. 2. Is the cloth lightly wet with water and used to clean the mirror from top to bottom?
Yes
No
N/A
3. 3. Are fingerprints, splash marks, and smudges removed as needed?
Yes
No
N/A
Section 13: Clean Wall Splash Marks
1. 1. Are the visually soiled wall areas cleaned?
Yes
No
N/A
2. 2. Is a damp yellow microfiber cloth used to clean the walls?
Yes
No
N/A
3. 3. Are the grab bars and the wall behind them wiped clean?
Yes
No
N/A
4. 4. Is the cloth disposed of in the dirty linen bag?
Yes
No
N/A
Section 14: Restock Paper Supplies And Empty Trash
1. 1. Are paper supplies restocked, including poly liners, toilet paper, paper towels, folded towels, soap, and personal items?
Yes
No
N/A
2. 2. When disposing of waste, is care taken to avoid sharp objects that may pierce the plastic liner, and is the open end of the liner gathered and tied closed with a knot?
Yes
No
N/A
3. 3. Is the toilet flushed and the restroom exited?
Yes
No
N/A
Section 15: Dust Mop Floor
1. 1. Are obstructions on the floor checked and removed with a scraper before beginning dust mopping?
Yes
No
N/A
2. 2. Is a green microfiber 18" dust pad used, starting from the farthest corner of the room and working backward?
Yes
No
N/A
3. 3. Is the dust mop kept on the floor and used to clean under furnishings and beds, paying special attention to corners?
Yes
No
N/A
4. 4. When dust mopping in front of the restroom, is debris pushed into a pile by the door before entering the restroom to continue dust mopping?
Yes
No
N/A
5. 5. Is all dust collected at the exit door with a broom and dustpan, then dumped into the cart’s waste container?
Yes
No
N/A
Section 16: Damp Floor Mop
1. 1. Is a wet floor sign placed in the doorway to alert residents, guests, and staff of the wet floor?
Yes
No
N/A
2. 2. Is a properly charged blue damp mop used, starting from the farthest corner of the room and working backward towards the entrance and restroom?
Yes
No
N/A
3. 3. Is the mop used to clean as far under furnishings and beds as possible, with particular attention to corners?
Yes
No
N/A
4. 4. When mopping in front of the restroom door, is the restroom entered and mopped from the far corner, ensuring all fixtures, sinks, and behind the toilet/urinal are cleaned?
Yes
No
N/A
5. 5. Is mopping continued backward out of the resident’s room door?
Yes
No
N/A
6. 6. Is the damp mop pad removed and placed in the dirty linen bag on the cart, with only one pad used per resident room?
Yes
No
N/A
Section 17: Carpet Disinfection
1. 1. Is the vacuum cleaner plugged into a centrally located outlet to increase productivity?
Yes
No
N/A
2. 2. Are strokes overlapped slightly until the entire area is vacuumed, using accessories for hard-to-reach areas?
Yes
No
N/A
3. 3. Is spot cleaner applied directly to stains following specific label instructions, using a circular motion outside the spot’s perimeter?
Yes
No
N/A
4. 4. Is time allowed for the area to dry, followed by using a tapping brush and blotting with a white towel to absorb soil?
Yes
No
N/A
5. 5. Is the area rinsed thoroughly with clean water, and once dried, is any remaining residue removed with the vacuum?
Yes
No
N/A
6. 6. Are rugs and door mats laundered regularly according to manufacturer instructions?
Yes
No
N/A
Section 18: Final Steps
1. 1. Upon finishing, is the resident informed that cleaning is complete, and is the safety sign removed if the floor is dry? If it is still wet, is the sign removed later?
Yes
No
N/A
2. 2. Is PPE properly doffed and hand hygiene performed to ensure contamination is not spread?
Yes
No
N/A
3. 3. If the room is empty, is the supervisor or nurse’s station notified that the discharge unit is now ready for use?
Yes
No
N/A