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| CDI=Corrected During Inspection | |
R=Repeat Violation | |
VR=Verification Required | |
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| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
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|---|
|
7
|
1
|
Facilities provided, accessible, clean, good repair |
No |
No
|
No |
REPEAT
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed loose toilet seat in room 666, damaged (peeling paint) toilet seat in room 273, damaged (holes on the bottom side caused from screw handles) toilet seat in room 295. Soiled on the bottom side of shower chair in room 295. Toilet in room 185 and spa in memory care start to chip away where the seat come down in contact with. Observed slow drain in hand sink in healthcare spa. Need repair/replace where appropriate. -1 pts- |
|
8
|
0.50
|
Toilet rooms free of storage, handwash signs posted |
No |
No
|
No |
.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed two fabric chairs store in memory care spa waiting to be clean. Chairs was taken out and placed in an appropriate storage at the time of inspection.
.1312 (b) A sign shall be posted in each toilet room for institution employees, directing them to wash their hands after each visit to the toilet room and before returning to work. Observed no hand washing signs posted in restroom where employees have access to in skill nursing. EHS provided hand washing signs at the time of inspection. -0.5 pts- |
|
10
|
0
|
Handwashing facilities properly located and equipped |
No |
No
|
No |
.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices. Observed no paper towel in AL oxygen room, healthcare storage room, and skill nursing storage room. Paper towel was provided at time of of inspection. Observed no soap and paper towel in the salon hand sink. Ensure to provide all hand washing supplies at all hand sink at all time. -0 pts- |
|
17
|
0.50
|
Back-up water supply plan available and complete |
No |
No
|
No |
REPEAT
.1313 (e) The institution shall have a written plan to obtain a backup water supply in the event that the institution's primary water supply is interrupted for more than four consecutive hours. The written plan shall identify a backup water supply or alternate source of water that provides two liters of potable water per day per resident and institution employee for drinking and potable water for food preparation, hand washing, bathing, cleaning, dishwashing, laundry, and disposal of bodily waste. This may include a plan for relocating residents to a facility with a water supply that satisfies Paragraph (a) of this Rule. If an institution's primary water supply or backup water supply becomes unsafe for human consumption, then the water sources within the institution, such as sink faucets, shall be labeled or hooded to prevent their use, and the administrator shall provide potable water for use by the institution's residents and employees. Observed the facility with incomplete back up water supply plan, details of how the plan will be implemented in the event of lost water for more than 4 consecutive hours needed. EHS emailed administrators a BACKUP WATER SUPPLY PLAN CHECKLIST. The facility will be working on getting details plan in place. -0.5 pts- |
|
18
|
0
|
Drinking fountains clean, good repair |
No |
No
|
No |
.1314 (a) Drinking fountains shall be kept clean and in good repair. Observed water fountain in healthcare needs cleaning and keep clean even when it is not in service. -0 pts- |
|
32
|
0
|
Furnishings clean and in good repair; mattresses dry, clean, good repair |
No |
No
|
No |
.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair. Observed damaged pillows in room 105 in memory care, 667 in skill nursing. Replace the hospital pillow as needed when it is damaged. |
|
33
|
0.50
|
Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled |
No |
No
|
No |
.1319 (b) A resident's bed linens shall be changed when no longer clean. Observed soiled bed linen and pillow case in room 653. Change bed linens when visibly soiled. -0.5 pts- |
|
38
|
0.50
|
Food service equipment and utensils clean, good repair |
No |
No
|
No |
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed refrigerator and microwave in skill nursing, refrigerator in memory care in need of detail cleaning. -0.5 pts- |
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