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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 |
|
|---|
|
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 cleaning needed on floors in soiled utility rooms on 7th and 8th floors. |
|
2
|
1
|
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 wall damage in SPD. Observed damaged walls and build up on walls in soiled utility in ICU. Observed wall edging loose at entrance to Equipment storage in ICU. Observed stained ceiling tile in room just inside the door on unit 5D. Repeat. No escalation in points. |
|
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 draining slow (end of hall in Endo near nuclear medicine hallway). Clean around hand sink faucets and toilets in Endo, ED, Radiology. Observed leaking tub faucet and cracked shower handle backing in room on 5D. Observed tub room with stained shower tiles in Neuro ICU. Repeat. No escalation in points. |
|
10
|
0
|
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 paper towel dispenser not operating in PICU 7. |
|
16
|
3
|
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 92-102F in ED guest restroom, ED B station, ED A station. 75-81F in Radiology ultrasound, CT scan, and 118F at Endo sink at end of hallway. 75-78F in room 735 on 7E. Observed hot water reach 99F in PACU and 120F in PICU 7. Observed 6F having 120F-121F at hand sinks throughout. Observed water at 118 in room at 5D. Observed Water at 119 in 5813. Repeat. |
|
21
|
0
|
Approved sewage disposal |
No |
No
|
No |
.1315 (a) All sewage originating from the institution shall be disposed of using a publicly operated sewage treatment plant or an individual sewage disposal system that meets the requirements of Section .1900 of this Subchapter. Observed mop sink in soiled utility in 5A clogged and not draining. |
|
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 tear on seat cushion in room 769. Work order submitted during the inspection. Observed damaged couch cushion and laminate under couch in 5813. Observed laminate on counter peeling in soiled utility in 5F. |
|
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 fridge, cabinets and microwave in need of cleaning in nourishment 2 on 5F. Observed microwave and fridge in need of cleaning in nourishment 1 of 5F. Observed cabinets in nourishment room in need of cleaning in CCU and 5C. |
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