| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
1
|
1
|
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 damaged/peeled floor tiles near soiled room in Labor and Delivery. Observed black residue on floor tiles in shower in room 767 on 7C. |
|
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 wall scuffed / damaged in patient room #3104 in need of touch-up painting / repair. |
|
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 soiled toilets with ring around the bowl, soiled sinks all around basin, drain, faucet need cleaning in Radiology, Radiology Holding, CT scan department, Flora department, Emergency Department. Observed slow drain need repair at public restroom ED, Flora department, Radiology Holding, ED area A-B. Observed sink need new caulking and repair in ED public restroom, ED nourishment sink in D area. |
|
8
|
0
|
Toilet rooms free of storage, handwash signs posted |
No |
No
|
No |
.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 in staff restroom in Endoscopy. |
|
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 no soap available in soiled utility room ED- D area and no paper towels in soiled utility room in Endoscopy. Ensure to provide all hand washing supplies at all hand sinks at all time. |
|
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 at 83F in neuro ICU. Observed automatic sink in room 6329 and soiled utility in intermediate ICU not operating. Observed hot water measured at 123F in CT scan 1, the entire unit of Endoscopy at 125F, and Flora restroom at 90F. REPEAT. |
|
20
|
0
|
Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair |
No |
No
|
No |
.1314 (c) Ice shall be protected against physical, chemical, and biological contamination and shall be kept clean. Observed build up in ice chute of ice machine in NICU and in Mother/Baby nourishment. |
|
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 residue on shower curtain in 767 on 7C. Observed chair cushion ripped in room 802 on Mother/ Baby. Observed clean supply room in (3C) having soiled shelving in need of general cleaning. Observed toilet seat loose in BH 704. |