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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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|---|
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1
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2
|
Floors and carpets cleanable, clean, good repair; carpet odor free |
No |
No
|
No |
REPEAT
1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair.- Observed debris on flooring underneath shelving in closets, sticky floor, debris on flooring throughout the room or along edges in room 302, 814, 706, 707, 403, and other several residents rooms. Detail cleaning needed. Keep flooring throughout the facility clean. |
|
7
|
2
|
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 damaged ceiling in front of room 603 need repair. Observed faucet needs repair in room 403. Observed soiled hand sinks/ soiled toilet in activity room, soiled utility room near the front, spa 300 hall, room 315, 506, 600, 701, 706, 914, 911, 113, 106, 101, 302, spa room in arboretum. Observed damaged toilet seat need repair or replace in room 315, 600, 706, 701. Details cleaning needed. Keep all toilets and sinks clean. |
|
8
|
0.50
|
Toilet rooms free of storage, handwash signs posted |
No |
No
|
No |
REPEAT
.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed wheelchair, dining roller table chair lift stored in Spa room rehab, and spa on garden C hall. Only store bathroom related items in bathroom facility.
.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 posted in staff restroom in rehab. EHS provided hand washing sings to PIC at the times of inspection. |
|
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 the incomplete written plan for backup water supply. The facility still has a plan template (filling information) of health department checklist. The facility shall have their own plan according to the need of their facility. The health department checklist is a guide to complete your own written plan. Obtain a complete detailed plan and have available upon request. |
|
28
|
0
|
No pest presence; effective pest control measures |
No |
No
|
No |
General comment:
.1317 (a) Pests shall not be present in an institution's building or buildings.- Observed drain flies in room/restroom 106, 600. During inspection, the resident in room 600 and 604 mentioned that aunts are in their room. Ensure to keep the facility free of pests. |
|
38
|
0.50
|
Food service equipment and utensils clean, good repair |
No |
No
|
No |
REPEAT
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair.- Observed soiled microwaves need cleaning and keep clean in nourishment rooms. |
|
43
|
0
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Food brought into the institution by employees or visitors of patients or residents properly stored, labeled and dated |
No |
No
|
No |
General Comment:
.1321 (b) Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply as described in rule .1321 (a). Such food shall be labeled with the name of the resident or employee that the food belongs to and the date the food was brought into the institution. Labeling as required by this Rule shall not be required for food items stored in employee-designated or individual residents' refrigerators or rooms.
- Observed residents food in refrigerator of nourishment room in arboretum without name and date. Ensure to label each items with name and date. |
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