| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
2
|
0
|
Walls and ceilings clean, good repair |
No |
No
|
No |
Observed stained ceiling tile in room 5329. Observed stained ceiling tile in 3004 soiled utility. Observed wall and ceiling chipping in Radiology bathroom and Ed Care.
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. |
|
5
|
0
|
Ventilation equipment clean, good repair |
No |
No
|
No |
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed broken air filter in A/C unit in 322. |
|
7
|
0
|
Facilities provided, accessible, clean, good repair |
No |
No
|
No |
Observed black residue around shower floor in room 737, 718. Detail cleaning needed. Observed cracked paper towel dispenser (ED Care Bthrm A). Low pressure ED #15.
.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. |
|
8
|
0
|
Toilet rooms free of storage, handwash signs posted |
No |
No
|
No |
Observed no hand washing sign in restrooms where staff have access to. Hand washing signs need to be posted. |
|
10
|
0
|
Handwashing facilities properly located and equipped |
No |
No
|
No |
Missing soap dispenser in ED side A soiled utility.
.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices. |
|
16
|
1.50
|
Hot water between 105°F and 116°F |
No |
No
|
No |
Observed hot water ranging from 93-98F on floors ICU, 5A, 5C, 5F, and NICU (nourishment and rooms). Observed hot water at 91F in ACU before reaching 101F. Observed hot water at 100/101 F in 6829. Observed water in 3317 at 95F. Observed water in 3110 at 91/102F. Observed hot water at 89F in 3121. Observed hot water measured between 68F - 102F throughout the floor on 7E & 7D unit. Observed hot water 85F throughout Rad and ED.
.1313 (d) Institutions shall provide water heating facilities. Hot and cold running water under pressure shall be provided to carry out all operations. Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities. |
|
18
|
0
|
Drinking fountains clean, good repair |
No |
No
|
No |
.1314 (a) Drinking fountains shall be kept clean and in good repair. Observed 1 water fountain out of order on 7th floor maternity unit. |
|
20
|
0
|
Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair |
No |
No
|
No |
Observed black residue around ice chute of ice machine in nourishment area of 5A.
.1314 (c) Ice shall be protected against physical, chemical, and biological contamination and shall be kept clean. |
|
28
|
0
|
No pest presence; effective pest control measures |
No |
No
|
No |
Observed drain flies in restroom 737, and room 710 |
|
32
|
0
|
Furnishings clean and in good repair; mattresses dry, clean, good repair |
No |
No
|
No |
Observed torn pillow in room 11 on ICU. Observed damaged shelf in cabinet in nourishment area in CCU. Observed cabinets in T3009 with debris build up. Observed cleaning needed under family bed in 35 Hospice. Observed cabinet hinge broken in 35 hospice. Observed damaged wheelchair with duck tapes on to hold it together. Observed cuts and tears on guest sofa in room 7807. Need repair or replace. |
|
33
|
0
|
Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled |
No |
No
|
No |
Observed soiled linen not labeled or bag was backwards, or label was faded in several areas (ED or radiology).
.1319 (b) Bed linens that are provided by the institution for use by residents shall be free from holes and tears. |
|
38
|
0
|
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 detailed cleaning needed to microwaves in nourishment rooms on 8th floor on maternity unit and in 4D nourishment area. |