| 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 floors need sweeping/vacuuming in locked areas including behind doors, throughout. |
|
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 walls need repairs where soap dispensers have been changed out. Repair scuff marks from wheelchairs and chairs in common areas. |
|
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 shower chairs and toilet chairs the need cleaning on the undersides. |
|
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. Staff bathrooms or common bathrooms staff use must have hand wash signs. |
|
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 several emesis basins that’s needed cleaning in several rooms.
.1312 (c) Institutions where bedpans, bedside commodes, urinals, or emesis basins are used shall provide facilities for emptying, cleaning, and disinfecting bedpans, bedside commodes, urinals, and emesis basins. Observed emesis basins and urinals not labeled throughout. |
|
12
|
0
|
Bathing facilities properly equipped, equipment cleaned and disinfected |
No |
No
|
No |
.1312 (f) Bathing equipment that has contact with a resident's skin and is used by more than one resident shall be kept clean and shall be disinfected between resident uses. Equipment located within a bathing facility that uses a pump to move water shall be kept clean in accordance with the manufacturer's instructions. Observed no disinfectant or disinfecting instructions posted for proper cleaning of spa with pump |
|
17
|
0
|
Back-up water supply plan available and complete |
No |
No
|
No |
.1313 (e) The institution shall have a written plan to obtain a backup water supply in the event that the institution's primary water supply is interrupted for more than four consecutive hours. The written plan shall identify a backup water supply or alternate source of water that provides two liters of potable water per day per resident and institution employee for drinking and potable water for food preparation, hand washing, bathing, cleaning, dishwashing, laundry, and disposal of bodily waste. This may include a plan for relocating residents to a facility with a water supply that satisfies Paragraph (a) of this Rule. If an institution's primary water supply or backup water supply becomes unsafe for human consumption, then the water sources within the institution, such as sink faucets, shall be labeled or hooded to prevent their use, and the administrator shall provide potable water for use by the institution's residents and employees. Observed incomplete back-up water supply plan that does not account for bathing or bathroom waste disposal. |
|
19
|
0
|
Multi-use utensils for service of ice and water cleaned, sanitized, good repair; single use utensils not reused |
No |
No
|
No |
.1314 (b) Disposable, single-service utensils shall be used by only one person. Observed drinking cups in rooms not labeled. cover cups in dispenser with no lid in PT room. |
|
30
|
1
|
Medication carts clean; sharps containers attached; food, utensils, medication and medication dispensers properly handled |
No |
No
|
No |
.1318 (a) Food, utensils, medications, and equipment used on medication carts shall be kept clean. Observed hand sanitizer stored on sharps containers of med carts. Store elsewhere. Debris in bottom of bags holding pill cups and drinking cups. |
|
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 stained chairs in common areas throughout. Some swivel chairs in common rooms with torn arms. Torn covering on PT equipment in PT room. Salon needs good general cleaning. Mattress frayed in room 202 . Rusted toilet chair room 607. Damaged tables, 400 hall. Broken recliner room 111. Storage cabinets need cleaning/wiping out in locked areas. |
|
33
|
0
|
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 soiled linen cart not labeled in dirty side central laundry. |
|
52
|
0
|
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. Observed facility is going to assemble kits with written vomit/diarrheal plan/cleaning instructions for each neighborhood. |