| 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 storage room floors collecting debris. Recommend elevating storage off the floor to facilitate cleaning. Keep all floors clean. |
|
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 minor wall damage in resident and storage rooms. Keep all walls in good repair. |
|
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 spas with non-functioning lights. Replace any non-functioning bulbs. |
|
5
|
0
|
Ventilation equipment clean, good repair |
No |
No
|
No |
.1311 (b) Ventilation equipment shall be kept clean and in good repair in suite 114/113. Keep all ventilation equipment clean. |
|
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 bathing chairs in rooms 314, 330, and 114, with brown residue. Observed toilet seat loose in 200 Spa room. Observed rusted toilet chair in room 201. Observed damaged backsplash at therapy bathroom and activity room sinks. Observed water damaged cabinet under sink in therapy room. Observed medication room sinks with debris and residue. Observed one shower curtain in 322 with pink residue. |
|
8
|
0.50
|
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 spa areas that contain toilets with non-bathroom related storage such as floor pads and positioning pads. Remove all non bathroom/toilet room related storage. |
|
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 the 100 spa room and one utility room with no hand washing soap. |
|
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 spa tub missing disinfectant inside the tub that is used to circulate and disinfect the tub. Observed a VitalOxide product that indicates that it is a non-rinse sanitizer in a Spa room. Replace the product with a hospital grade disinfectant and remove the sanitizer from the spa area. |
|
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.
The back up water supply information provided in the emergency response manual does not address the following: Hooding faucets and water fountains when water is not safe for human consumption. Amount of water provided per resident/employee per day. A loss of water procedures for hand washing, bathing, cleaning, and disposal of bodily waste. |
|
23
|
0.50
|
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 dumpster missing a lid and dumpster sliding doors left open. Keep the dumpster doors and lids closed. |
|
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 living room couches throughout the facility collecting debris and one couch with a medication under the pillows. Clean all couches and clean daily. Observed damaged mattress in room 314. Keep all mattresses in good repair. |
|
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. Observed soiled towels in room 114/113 bathroom on the floor. Place soiled linen in a covered container once used. |
|
35
|
0
|
Resident’s personal laundry properly handled; containers properly labeled; combined resident’s laundry properly handled |
No |
No
|
No |
.1319 (d) Clothing and linens that are provided by a resident for the resident's personal use shall be that resident's personal laundry. Personal laundry that is not clean shall be kept separate from clean clothing and linens using covered containers or bags that are labeled to indicate their contents and kept clean between uses. Observed a non-occupied/clean room, 301, with clothing from the last resident under the mattress. Keep resident clothing separate from clean linen and ensure resident items are removed between each resident. |
|
36
|
0
|
Laundry area and equipment kept clean |
No |
No
|
No |
.1319 (e) Laundry areas and equipment shall be kept clean. Observed melted plastic inside one dryer. Keep all laundry equipment in good repair. Observed personal food on the clean linen folding table, keep laundry equipment clean. |
|
37
|
0
|
Wheelchairs, walkers, lifts, and other mobility equipment properly cleaned and sanitized |
No |
No
|
No |
.1319 (f) Wheelchairs, walkers, lifts, and other mobility equipment shall be kept clean and sanitized between uses by different residents. Observed damaged wheelchairs in the therapy room and in room 330. Replace damaged wheel chairs so they can be be cleaned and sanitized between users. |
|
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 no vomit or fecal matter clean up plan available. Provide a written plan and maintain available for staff and review during the inspections. |