Free · Excel & Google Sheets
Free Assisted Living Survey Readiness Checklist (Excel, Google Sheets & PDF)
A free 50-item survey readiness checklist for assisted living, in seven groups: license and postings, staff files, resident files, medication, fire safety, environment and food, and policies. Record an owner, the date you last checked, the finding and where the proof is, and each item turns red, amber or green.
In the file
5 sheets · 159 KB · opens in Excel, Google Sheets and LibreOffice
- Start here
- Checklist
- Dashboard
- Import to ExpiryEdge
- Lists
Prefer a plain list? The CSV (9 KB) has the same columns and example rows, without formulas or colors.
Preview
The tracker sheet, with example rows
This is the color logic the spreadsheet uses. Move the date to see which rows turn amber or red next.
assisted-living-survey-readiness-checklist-us.xlsx
| Group | Checklist item | Owner | Next check | Days left | Status |
|---|---|---|---|---|---|
| License and postings | Current license posted in a public area, with capacity and class matching your actual census and services | Administrator | Dec 15, 2026 | 78 | Due ≤90 days |
| License and postings | Latest statement of deficiency (SOD) and any enforcement notice posted | Administrator | Oct 1, 2026 | 3 | Due ≤30 days |
| License and postings | Most recent inspection report and plan of correction displayed where residents and visitors see notices | Administrator | Dec 15, 2026 | 78 | Due ≤90 days |
| License and postings | Resident rights, house rules and grievance procedure posted | Administrator | |||
| License and postings | Long-term care ombudsman poster posted, with the office's name, address and phone number | Administrator | |||
| License and postings | Activity schedule posted | Administrator | |||
| License and postings | Copy of your state's assisted living rule kept on site | Administrator | |||
| Staff files | Written job description in every employee file | Office or HR lead | |||
| Staff files | Caregiver background check at hire, and repeated on your state's cycle | Office or HR lead | Nov 20, 2026 | 53 | Due ≤90 days |
| Staff files | Tuberculosis (TB) screening documented before hire | Office or HR lead | Dec 1, 2026 | 64 | Due ≤90 days |
| Staff files | Standard precautions training completed before any task with exposure to body fluids | Office or HR lead | |||
| Staff files | Fire safety training completed | Office or HR lead | Oct 25, 2026 | 27 | Due ≤30 days |
| Staff files | First aid and choking training completed | Office or HR lead | |||
| Staff files | Medication administration training completed before the employee passes medications, with trainer approval number recorded where required | Office or HR lead | |||
| Staff files | Registered nurse (RN) delegation records on file for delegated tasks, where your state uses delegation | Office or HR lead | |||
| Staff files | Certified nursing assistant (CNA) or certified medication aide (CMA) registry status checked and expiry dates logged | Office or HR lead | |||
| Resident files | Pre-admission assessment, updated at least annually and after any change in condition | Resident care lead | |||
| Resident files | Physician report or physical exam on file | Resident care lead | |||
| Resident files | Temporary service plan written on admission | Resident care lead | |||
| Resident files | Individual service plan completed, signed by the resident or representative | Resident care lead | |||
| Resident files | Service plan reviewed annually or at a change in condition, with the review documented | Resident care lead | |||
| Resident files | Evacuation capability assessment | Resident care lead | Dec 10, 2026 | 73 | Due ≤90 days |
| Resident files | Current medication list with dose, directions and changes in condition | Resident care lead | |||
| Resident files | Advance directives, guardianship or power of attorney papers on file where applicable | Resident care lead | |||
| Resident files | Annual resident satisfaction evaluation offered | Resident care lead | |||
| Medication | Medication cart and room audit: locked, clean, labeled and organized by resident | Medication lead | |||
| Medication | Expired, discontinued and recalled medications pulled and destroyed under your written disposal policy | Medication lead | |||
| Medication | Discontinued medications not held past your state's limit | Medication lead | |||
| Medication | Controlled substances stored in a separate locked compartment | Medication lead | Jan 1, 2027 | 95 | OK |
| Medication | Controlled-substance count sheets complete, signed and reconciled, with every discrepancy investigated | Medication lead | |||
| Medication | Medication administration records (MARs) match current orders, with no blank doses | Medication lead | |||
| Medication | Pharmacist or physician medication regimen review on file | Medication lead | |||
| Fire and life safety | Fire drill log with date, time and total evacuation time | Maintenance lead | Dec 30, 2026 | 93 | OK |
| Fire and life safety | At least one drill a year that simulates sleeping-hours conditions with overnight staff | Maintenance lead | |||
| Fire and life safety | Tornado, flood or other disaster drills logged | Maintenance lead | |||
| Fire and life safety | Annual fire inspection report by the local fire authority, kept for 2 years | Maintenance lead | |||
| Fire and life safety | Fire extinguishers inspected annually by a qualified professional, with a dated tag on each | Maintenance lead | |||
| Fire and life safety | Smoke detector tests logged and sprinkler inspection reports filed | Maintenance lead | |||
| Fire and life safety | Kitchen hood suppression inspection report current under your fire code | Maintenance lead | |||
| Fire and life safety | Exits and corridors clear, exit diagram posted and emergency numbers posted near staff phones | Maintenance lead | |||
| Environment and food | Hot water temperatures checked and logged at resident taps | Kitchen lead | |||
| Environment and food | Food temperature logs complete for cooking, holding and refrigeration | Kitchen lead | |||
| Environment and food | Food stored off the floor, covered, labeled and dated, with nothing past its use-by date | Kitchen lead | |||
| Environment and food | Weekly menus written and available to residents, and dated menus kept | Kitchen lead | Nov 5, 2026 | 38 | Due ≤90 days |
| Environment and food | Chemicals and hazardous materials stored securely, with no trip, burn or entrapment hazards on the tour route | Kitchen lead | |||
| Policies and incidents | Policies and procedures reviewed and dated, matching the current version of your state rule | Administrator | |||
| Policies and incidents | Incident reports complete, each with an investigation and follow-up action | Administrator | |||
| Policies and incidents | Self-reports to the state agency filed, with copies accessible on survey day | Administrator | |||
| Policies and incidents | Grievance log with a written summary of findings and action for each grievance | Administrator | |||
| Policies and incidents | Records kept for your state's retention period | Administrator |
2 due ≤30 days, 6 due ≤90 days, 2 OK. The example dates are fixed, so as real time passes more of them turn amber and red: that is the formula working.
How to use it in 3 steps
Name an owner per group
The owners are pre-filled with suggested roles. Replace them with names and add a backup, so every group has someone who keeps it right.
Run a 3-hour gap audit
Pull 5 staff files and 5 resident files, score each item against them, then walk the building. Type the date, the finding and where the proof is. Anything you cannot find in 5 minutes counts as not met.
Fix red first, then keep it green
The Dashboard counts red, amber and green by group and lists the first 10 red items. Each item comes back for a re-check every 3 months unless you set your own interval.
What’s inside
- Start here
- How to run the gap audit in five steps, the colour key and what every column means.
- Checklist
- The 50 items in seven groups with owner, last checked, finding, evidence location, next check and a calculated red, amber or green status.
- Dashboard
- Red, amber and green by group, % green, the first 10 red items and the next 10 re-checks.
- Import to ExpiryEdge
- Checked items in the ExpiryEdge bulk-import columns, filled by formula.
- Lists
- The group names behind the dropdown.
Open it in Google Sheets
There is no shared Google copy to request access to. You import the same file, so you own your copy from the start.
Download the .xlsx
Use the button above. It saves straight to your computer.
Import it into a blank Google Sheet
Open Google Sheets, create a blank spreadsheet, then choose File › Import › Upload and pick the file. Select "Replace spreadsheet".
Check the dates
Formulas, dropdowns and status colors carry over. If your Google account uses a different locale, dates show in that format, which is fine: they are real dates underneath.
Columns explained
Type in the input columns. Calculated columns fill themselves. Columns marked required are the ones the import sheet needs.
| Column | What to enter | Type |
|---|---|---|
| Group | One of the seven checklist groups. The dashboard counts by group. | Input |
| # | Item number, matching the printable PDF. | Input |
| Checklist item | What a surveyor would check. Edit the wording to match your own state rule. | Input · required |
| Rule example (check your state) | Where a number comes from. Most are Wisconsin (DHS 83) or Georgia (111-8-62) examples: replace them with your own state's rule. | Input |
| Owner | The person who keeps this item right. Pre-filled with a suggested role: replace it with a name. | Input |
| Backup owner | Who covers when the owner is off. | Input |
| Owner email | Who should be reminded. Becomes notification_email on import. | Input |
| Last checked | Date you last checked this item against real files or the building. | Input |
| Finding | Met, Partly met, Not met or N/A. Score a sample of files: anything you cannot find in 5 minutes counts as not met. | Input |
| Evidence location | Where a surveyor would find the proof: binder tab, folder or system. Blank counts as Red. | Input |
| Re-check every (months) | How often to re-check. Blank = 3 months (our suggestion, not a rule). Use 1 for items that drift fast, such as medication counts. | Input |
| Next check | Calculated. Last checked plus the re-check interval. | Calculated |
| Days to next check | Calculated. Negative once the re-check is overdue. | Calculated |
| RAG status | Calculated. Red = not met, no evidence location, or re-check overdue. Amber = partly met or re-check due within 30 days. Green = met with evidence. Also Not checked and N/A. | Calculated |
| Why | Calculated. The reason for a Red or Amber status. | Calculated |
| Notes | Anything the next person needs to know. | Input |
When a spreadsheet stops being enough
For a handful of dates and one careful owner, this template is all you need. These are the signs it has become the wrong tool.
Sign 1
More than one person owns the dates
When several people add rows, dates get typed as text, copies drift apart and nobody is sure which file is current.
Sign 2
Reminders depend on someone opening the file
The status turns red whether or not anyone is looking. If the person who checks it is on leave, the date passes quietly.
Sign 3
You need to prove what happened
An audit, insurer or inspector may ask who was told, when, and where the certificate is. A spreadsheet does not keep that history.
When you would rather not remember
What this looks like when it runs itself
The same row, tracked for you: an owner, reminders at 90, 60, 30 and 7 days by email, SMS, WhatsApp, Slack or Teams, the document on file and a log of who did what. The "Import to ExpiryEdge" sheet in this template is already laid out for Bulk Import, so moving across is one upload.
Try it with your own dates, free for 14 days, no cardExpiryEdge · Tracked item
Evacuation capability assessments · all residents
ValidOwner
Resident care lead
Expires
Jan 10, 2027
Reminders before expiry
90d
60d
30d
7d
Due
Assisted living survey readiness checklist: questions, answered
Surveyors check whether your records, postings and daily practice match your state rule. Wisconsin’s survey guide describes a document list at the opening meeting, then a tour, private interviews, record review, a safety code review and an exit conference. The 50 items follow that pattern in seven groups.
Our State Survey Readiness Checklist is built for skilled nursing and long-term care facilities, which meet federal requirements in 42 CFR Part 483. Assisted living is licensed by each state, so this version follows state assisted living rules instead: staff and resident files, postings, medication, fire safety and food.
Not necessarily. The rule examples come mostly from Wisconsin’s CBRF rule (DHS 83) and Georgia’s personal care home rules. Use the 50 items as the structure and overwrite the numbers with your own state’s rule.
Red means the item is not met, has no evidence location, or its re-check date has passed. Amber means partly met or a re-check due within 30 days. Green means met with the proof location recorded. Items not yet checked and items marked N/A are counted separately.
Yes. Open a blank Google Sheet, choose File › Import › Upload, pick the .xlsx and select "Replace spreadsheet". The formulas use only functions that Google Sheets, Excel and LibreOffice all support (no FILTER, SORT or XLOOKUP), so the status colours, dropdowns and dashboard carry over. The Excel table styling becomes a plain range with filters.
No. A spreadsheet only changes when someone opens it, so the colours are only as good as your habit of checking. Put a weekly calendar slot on it, or move the survey items into a tool that sends the reminders for you.
It is free to download, use, change and share inside your organisation. There is no sign-up and no email needed: the download starts when you click.
A free template, not legal advice. It tracks the dates you enter; it does not decide which licenses apply to you. Check requirements against the official source for your situation.