| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
1
|
2
|
Floors and carpets cleanable, clean, good repair; carpet odor free |
No |
No
|
No |
REPEAT
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/missing floor tiles in west shower rm #2. Rip in floor in bathroom R119. Observed soiled shower rooms floors throughout the facility need detail cleaning and kept clean. |
|
2
|
2
|
Walls and ceilings clean, good repair |
No |
No
|
No |
REPEAT
.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 and stained ceilings throughout facility. Filling up holes in wall and touching up paint on wall throughout the facility needed. Keep all wall in good repair. Observed Laundry room ceiling covered with dusts, needs cleaning. Soiled utility west with mold growth on wall. |
|
4
|
0
|
Lighting at least 10 foot candles, 30 inches above floor |
No |
No
|
No |
.1311 (a) The areas interior to an institution's building or buildings shall be equipped with at least 10 foot candles of light at 30 inches above the floor. Observed light fixtures not working in resident rooms over vanities, keep all light fixtures functional |
|
5
|
0.50
|
Ventilation equipment clean, good repair |
No |
No
|
No |
Repeat-.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed PTAC units in resident rooms with moderate to heavy dust build up in filters. |
|
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 blocked hand sink in laundry room, keep accessible without having to move carts. Observed loose toilet seat in west shower room #2.Repeat- Observed torn shower bed mattresses, unclean shower bed(s) and mattresses. Rusted toilet chairs. |
|
9
|
0.50
|
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 unlabeled and soiled urinals/bedpans in R218, R227, shower room #2 west |
|
10
|
1.50
|
Handwashing facilities properly located and equipped |
No |
No
|
No |
.1312 (d) Hand washing facilities shall be equipped with running water and a tempering device. Observed no hot water at hand wash sink in west soiled utility room.
.1312 (d) Repeat-Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices.Repeat- Observed no soap or paper towels in med room east, west shower room #2. |
|
17
|
0.50
|
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. Repeat- Observed incomplete back-up water supply plan. |
|
18
|
1
|
Drinking fountains clean, good repair |
No |
No
|
No |
REPEAT
.1314 (a) Drinking fountains shall be kept clean and in good repair. - Observed rusted and soiled water fountain in the therapy gym. Fountain on east hall not draining and backing up. |
|
23
|
0
|
Solid waste containers properly constructed, covered where required; good repair |
No |
No
|
No |
.1316 (a) All solid wastes containing food scraps or other putrescible materials shall be kept in leak-proof, non-absorbent containers which shall be kept covered with tight-fitting lids when not in use. Observed broken drain plug in dumpster. Replace drain plug. |
|
26
|
1
|
Premises properly maintained |
No |
No
|
No |
.1316 (d) An institution's exterior premises, including parking lots, lawns, and walkways, and interior premises within the institution's building or buildings, shall be kept free of garbage, solid waste, yard trash, and pest harborages. Observed container near dumpster corral holding water. Keep containers drained to prevent mosquito breeding. |
|
28
|
0.50
|
No pest presence; effective pest control measures |
No |
No
|
No |
.1317 (a) Pests shall not be present in an institution's building or buildings. Observed drain flies in both soiled utility room. |
|
30
|
0
|
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 pill cups stored in container on side of med-cart. Container is not easily cleanable, protect med cups by putting in a clean container or baggie. |
|
32
|
1
|
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. Repeat- Mattresses shall be kept clean, dry, and in good repair. Observed stained drapes and privacy curtains in majority of rooms checked. Many damaged bedside tables. Torn mattress in R218. Torn pillow in R218. |
|
33
|
0
|
Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled |
No |
No
|
No |
.1319 (b) Bed linens that are provided by the institution for use by residents shall be free from holes and tears. Repeat-Observed torn sheets in R218 |
|
45
|
0.50
|
Hot and cold holding equipment provided; thermometers provided, accurate |
No |
No
|
No |
.1323 (b) Hot and cold holding equipment shall be used to maintain the required temperatures for TCS food. Each refrigeration unit shall be provided with an indicating thermometer that is accurate to ±3 degrees Fahrenheit or ±1.5 degrees Celsius. Repeat- Observed no thermometer in refrigerator in east med room. |