| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
2
|
0
|
Walls and ceilings clean, good repair |
No |
No
|
No |
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. Observed multiple walls throughout the facility, such as memory care common area, room 128, damaged or scuffed in need of repair and/or repainting. |
|
5
|
0
|
Ventilation equipment clean, good repair |
No |
No
|
No |
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed air vent in memory care common area with heavy debris buildup, as well as multiple private resident bathrooms in memory care with dusty bathroom vent fans. |
|
7
|
2
|
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 toilets in multiple private resident bathrooms soiled and in need of cleaning. Observed a handful of toilets with loose seat cover in need of repair. Repeat. |
|
30
|
0
|
Medication carts clean; sharps containers attached; food, utensils, medication and medication dispensers properly handled |
No |
No
|
No |
.1318 (a) Food, utensils, medications, and equipment used on medication carts shall be kept clean. Observed medication cart in memory care area with patient cups over stacked, exposing the lips to possible contamination. Informed PIC to either keep smaller stacks of cups or keep covered from contamination. |
|
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 chair, pillow, and mattress in room 126 soiled or stained. Observed stained box spring in 125. |
|
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 chair, pillow, and mattress cover in room 126 soiled or stained. Observed more stained sheets in room 121, soiled mattress cover in 127, and soiled linens in 210. |
|
38
|
1
|
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 refrigerators in rooms 109, 210, 208, second floor common room, and memory care common room with food debris buildup and in need of cleaning. Observed microwave in room 210 and second floor common room soiled with food debris and in need of cleaning. Repeat. |
|
45
|
1
|
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 refrigerator in room 227 and second floor common room without thermometers. Observed refrigerators in rooms 210 and 208 with ambient temperature of 60 degrees. Repeat. |