| 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 cracked floor tile in A wing nourishment room. REPEAT. |
|
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 crack in therapy room kitchenette. Observed minor damage to walls in rooms throughout facility. Needs repair/touch up paint. |
|
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 shower bed mat torn in A wing shower. Observed some minor build up in A wing tub. Observed minor chipping on toilet seat in 107. Needs cleaning/repair. REPEAT. |
|
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 large rolling bins that contain soiled linen and trash stored in both shared spa rooms. REPEAT VIOLATION. |
|
9
|
0
|
Bedpans, urinals, bedside commodes and emesis basins properly cleaned and disinfected |
No |
No
|
No |
General Comment:
.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 a couple urinals and bed pans not labeled in rooms within facility. |
|
17
|
0
|
Back-up water supply plan available and complete |
No |
No
|
No |
General Comment:
.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 facility had parts of back up water supply plan such as drinking water, washing dishes, and flushing toilets spread out through multiple documents. Facility is missing some parts to back up water supply plan. EHS emailed a template for a back up water supply plan to facility management. |
|
32
|
0
|
Furnishings clean and in good repair; mattresses dry, clean, good repair |
No |
No
|
No |
General Comment:
.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 torn fall mat and heavily worn mattress in 113. Observed worn furniture in 201. Observed upholstery damage on chair in 107. Needs repair/replacement. |
|
38
|
1
|
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 refrigerator and microwave in need of cleaning in Activity room and some nourishment rooms. Observed cabinets in need of cleaning in A wing nourishment room. REPEAT. |
|
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 in A wing nourishment room refrigerator with either name or date label. Needs both name and date label. REPEAT. |