| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
1
|
0
|
Floors and carpets cleanable, clean, good repair; carpet odor free |
No |
No
|
No |
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 floors in need of cleaning in the following areas: 6D D697, 7FO common area, Room 7IM 727 floor tile with mold. |
|
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 damaged walls in 7D 799, wall and ceiling in SNU room 495. Wall damage and soiled, bathroom by CT. |
|
5
|
0
|
Ventilation equipment clean, good repair |
No |
No
|
No |
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed vents in need of cleaning and damaged in 6D D697 |
|
7
|
0
|
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 slow drain at handwashing sink in the restroom between bays #1 and #2 in ACU. Observed slow drain at handwashing sink in patient restroom in PACU. Hopper with residue ring, Endo soiled utility. Build up around sink fixture, ED #12. |
|
9
|
0
|
Bedpans, urinals, bedside commodes and emesis basins properly cleaned and disinfected |
No |
No
|
No |
.1312 (c) When disposable bedpans, emesis basins, and urinals are reused, they shall be labeled so that they are associated with an individual resident. Observed bedpans with no labeling in 7F 7802 |
|
16
|
0
|
Hot water between 105°F and 116°F |
No |
No
|
No |
.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. Observed hot water below temperature in some 7th floor areas below 100 F, 3C with hot water at 98 F. (Repeat, but observed improvement throughout facility). |
|
32
|
0.50
|
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 common group area furniture on the 7th floor in need of cleaning. Found debris in chair crevices. Treatment room table in need of cleaning and damaged pad in 7D exam room. Observed beds with rust under mattress in room 7F 7801 and 7802. Observed torn couch in room 5811. Observed cracked chair in 6107. Observed torn pillow in Cardiac ICU room 5 and room 6321. Frayed mattress ED #12. Soiled mattress on bottom side, ED hallway clean bed. Tear in scanner bed, CT scan. Torn pillow, CT scan. Tape residue on mattress, ultrasound exam 2. Room 849 chair in labor and delivery damaged. (Repeat) |
|
33
|
0.50
|
Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled |
No |
No
|
No |
.1319 (b) Linens that are not clean shall be placed in a covered container or bag devoted to this purpose at the point of use and stored in the covered container or bag until sanitized in accordance with Paragraph (c) of this Rule to contain and minimize aerosolization of and exposure to any waste products. Such covered containers or bags shall be kept clean between uses and labeled to indicate the contents. Observed exposed soiled linen in the following areas: 7F Soiled Utility room, 7IM Laundry room and room 7047. Many soiled linen carts not labeled in ED and Radiology.
.1319 (b) Bed linens that are provided by the institution for use by residents shall be free from holes and tears. Observed damaged bed linen in 6D D697. Torn sheet, isolation room ED. |
|
36
|
0
|
Laundry area and equipment kept clean |
No |
No
|
No |
.1319 (e) Laundry areas and equipment shall be kept clean. Observed interior of some 7th floor clothes washing machines with debris. |
|
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 food storage cabinets and refrigerators in need of cleaning and/or repair in the following areas. 6D nourishment, 7D nourishment. Observed build up in ICU nourishment 1 refrigerator. Observed build up in microwave in ICU nourishment room 2. Observed build up in refrigerator and microwaves in both nourishment rooms on 5F. Single Service cup dispenser without lid, ED. (Repeat) |