| Area / Item | Good | Needs Attention | N/A | Comments |
|---|---|---|---|---|
| Walls & Ceiling | ||||
| Floors / Carpeting | ||||
| Windows & Screens | ||||
| Doors & Locks | ||||
| Lights & Fixtures |
| Item | Good | Needs Attention | N/A | Comments |
|---|---|---|---|---|
| Toilet & Flush | ||||
| Sink & Faucet | ||||
| Shower / Tub | ||||
| Grab Bars | ||||
| Mirror |
| Item | Good | Needs Attention | N/A | Comments |
|---|---|---|---|---|
| Closet / Storage | ||||
| Bed & Mattress | ||||
| Chair / Table | ||||
| Telephone / Call System |
| Item | Good | Needs Attention | N/A | Comments |
|---|---|---|---|---|
| Sink & Faucet | ||||
| Refrigerator | ||||
| Microwave | ||||
| Cabinets / Drawers |