| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
1
|
2
|
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 general cleaning needed to flooring throughout facility. Observed some carpeted rooms with carpet staining. Observed floor tile damaged in restroom of 107. Observed laminate flooring bubbling in the bathroom outside of room 203. Observed flooring stripped in bathroom of room 402.
REPEAT VIOLATION. |
|
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 behind toilet in room 111. Observed wall baseboard also coming off from wall in restroom of room 111. Observed baseboard coming off from wall in bathroom of room 306.
REPEAT VIOLATION. |
|
5
|
0.50
|
Ventilation equipment clean, good repair |
No |
No
|
No |
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed dust accumulation to removable AV vents throughout facility. Observed dust accumulation to wall and ceiling vents throughout building. Observed dust accumulation to ceiling fan in laundry room. |
|
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 toilet throughout facility in residents rooms in need of detailed cleaning (toilet seat with brown build in room 111, pink ring within toilet bowl in room 301, toilet seat with brown build up in room 306). Observed detailed cleaning needed to flooring and toilets in shared bathing rooms located on 400 and 300 hallways.
Observed shower chair rusting in room 111. Observed toilet not operational in room 402. |
|
8
|
1
|
Toilet rooms free of storage, handwash signs posted |
No |
No
|
No |
.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed pile of linen stored on the floor in shared bathing facility located on 300 hallway. Observed pile of linen with brown debris under it stored in front of toilet located in shared bathing room located on 300 hallway. |
|
10
|
1.50
|
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 paper towels/hand drying device at handsink in shared bathing room located on 300 and 400 hallways. Observed no paper towels/hand drying device at handsink in the toilet room of room 303. |
|
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 not working in activity room and 1 with cleaning needed within drinking nozzle. |
|
25
|
0.50
|
Containers and areas clean; sufficient capacity |
No |
No
|
No |
.1316 (c) The designated rooms and containers described in rule .1316 (b) shall have the capacity to store the institution's refuse, recyclables, and returnables and shall be kept clean. Observed minor debris behind/surrounding dumpster area. Improvement made from previous report. |
|
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 black rolling chair armrest peeling in activity room. Observed general cleaning needed under couch cushions in activity room. |
|
33
|
0
|
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 staining on linen in room 105 |
|
34
|
1.50
|
Linens provided by the institution properly cleaned and sanitized |
No |
No
|
No |
.1319 (c) Linens provided by the institution that are not clean shall be cleaned and sanitized in accordance with this paragraph. When hot water in washing machines is used to sanitize linens provided by the institution, the washing machines shall be operated in accordance with the manufacturer's instructions. When chemicals are used to sanitize linens provided by the institution, linens shall be washed in accordance with the following:
(1) using a solution of at least 50 parts per million chlorine; or
(2) using laundry sanitizer that is registered in accordance with 40 C.F.R. 152 and that is used in accordance with the manufacturer's instructions.
Observed no documentation with facility to verify that notated rule is in compliance. REPEAT VIOLATION. During time of inspection, service provider was called and facility requested a copy of their last service report(report was not received before EHS left building). EHS advises facility to start keeping service reports onsite. |
|
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 general cleaning needed to the shelving of refrigerators stored on all units within facility to include activity kitchen. Observed refrigerator unit not functioning on 200 unit. |
|
43
|
1
|
Food brought into the institution by employees or visitors of patients or residents properly stored, labeled and dated |
No |
No
|
No |
.1321 (b) Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply as described in rule .1321 (a). Such food shall be labeled with the name of the resident or employee that the food belongs to and the date the food was brought into the institution. Labeling as required by this Rule shall not be required for food items stored in employee-designated or individual residents' refrigerators or rooms. Observed food not labeled stored in refrigeration units located on 100 hallway.
REPEAT VIOLATION. |
|
52
|
2
|
Vomitus and diarrheal clean up supplies; written clean up procedures available and complete |
No |
No
|
No |
.1324 (d) The institution shall have gloves, personal protective equipment, disinfectant, individual disposable towels, and a coagulating agent on-site for employees to use and a written procedure for employees to follow when responding to vomitus or fecal matter on institution surfaces. The procedure shall specify the actions that employees shall take to minimize the exposure of employees, residents, guests, food, and additional surfaces to vomitus or fecal matter. Per conversation with management, the kitchen has the required plan/procedure. EHS advised management that building portion of facility needs a procedure plan for notated rule as well. EHS resent facility copy of required plan. REPEAT VIOLATION. |