| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
5
|
0
|
Ventilation equipment clean, good repair |
No |
No
|
No |
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed minor dusts on air filter, ceiling vents in some rooms. Need cleaning and keep clean. |
|
7
|
1
|
Facilities provided, accessible, clean, good repair |
No |
No
|
No |
.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 hand sink in one of the spa rooms was blocked with no access to hand wash by bath bed and toilet chair. CDI- Maintenance removed items to provide access at the time of inspection. Ensure to provide access to hand washing sink at all time. Observed rusted toilet chair in room 105, 106, need repair or replace and keep in good repair. |
|
8
|
0.50
|
Toilet rooms free of storage, handwash signs posted |
No |
No
|
No |
.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 sign in the restrooms where staff have access. CDI- Hand washing signs provided at the time of inspection. |
|
10
|
1.50
|
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 soap in supply room on 100 hall. The paper towel dispensers without batteries or paper towels were out from it in room 112, spa rooms, supply storage rooms, soiled rooms. Ensure to provide all hand washing supplies at all hand sinks at all time. |
|
17
|
0
|
Back-up water supply plan available and complete |
No |
No
|
No |
.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 plan for water back up supply. EHS email the checklist for the plan to the administrator, details discussed at the time of inspection. The facility will put the plan together and have it complete by next inspection. |
|
20
|
1
|
Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair |
No |
No
|
No |
.1314 (c) Ice shall be protected against physical, chemical, and biological contamination and shall be kept clean. Observed ice chest and water cooler cart left out on the hallway in front of nourishment room. DCI- the cart put back in the lock nourishment room. |
|
30
|
0
|
Medication carts clean; sharps containers attached; food, utensils, medication and medication dispensers properly handled |
No |
No
|
No |
.1318 (a) Medication carts shall be kept clean. Observed medication carts need cleaning, spilling of liquid medication and debris inside. |
|
34
|
0
|
Linens provided by the institution properly cleaned and sanitized |
No |
No
|
No |
.1319 (c) Linens provided by the institution that are not clean shall be cleaned and sanitized in accordance with this paragraph. When hot water in washing machines is used to sanitize linens provided by the institution, the washing machines shall be operated in accordance with the manufacturer's instructions. When chemicals are used to sanitize linens provided by the institution, linens shall be washed in accordance with the following:
(1) using a solution of at least 50 parts per million chlorine; or
(2) using laundry sanitizer that is registered in accordance with 40 C.F.R. 152 and that is used in accordance with the manufacturer's instructions.
- Observed the facility has obtain the laundry records of august, September and November of 2022, and August of 2023. The facility need to keep all records on file as how often service was provided. |
|
45
|
0
|
Hot and cold holding equipment provided; thermometers provided, accurate |
No |
No
|
No |
.1323 (b) Hot and cold holding equipment shall be used to maintain the required temperatures for TCS food. Each refrigeration unit shall be provided with an indicating thermometer that is accurate to ±3 degrees Fahrenheit or ±1.5 degrees Celsius. Observed the refrigerator in the nourishment rooms need a thermometer inside for the temperature indication. |