| 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 floor in closets/storage/laundry rooms (behind washer and dryer) throughout building AL and MMcare need cleaning and keep clean. |
|
2
|
0
|
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 damaged door frame/trim in A hall bath Memory care need repair. Observed peeling paint on the ceiling in sell office at AL, need repair/paint touch up. |
|
5
|
0.50
|
Ventilation equipment clean, good repair |
No |
No
|
No |
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed dusts buildup on AC filter at the unit throughout the building AL and MMcare. Need cleaning and keep clean. |
|
7
|
0
|
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 loose toilet seats in restroom in AL hall way, room F10 and D8. Need repair and keep in good repair. |
|
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 wheelchairs, walkers, mirrors, items that are not bath related stored in D hall bath (MMcare), E and C hall toilet room (AL). Only store bath related/permitted items in bathrooms. |
|
11
|
0
|
EPA registered disinfectants used according to manufacturers' instructions; approved testing methods and devices used |
No |
No
|
No |
.1312 (e) EPA registered disinfectants shall be used in accordance with the manufacturer's instructions. When EPA registered disinfectants are mixed and prepared by institution employees, a measuring device, chemical testing device, or the methods and devices prescribed by the chemical manufacturer shall be used to prepare the concentration of chemicals in accordance with the disinfectant's label and the manufacturer's instructions. Observed housekeepers cleaning, when asked about chemical cleaning contact time, no one knows how to used chemical to clean effectively and the amount of contact time. The facility need to ensure cleaning staff is aware of how to clean effectively per manufactures instructions. |
|
16
|
0
|
Hot water between 105°F and 116°F |
No |
No
|
No |
.1313 (d) Institutions shall provide water heating facilities. Hot and cold running water under pressure shall be provided to carry out all operations. Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities. Observed hot water measure 121F - 124F in AL bathroom early morning. As time goes by, hot water temperatures are within range. Observed hot water temperatures in memory care unit range at 97F - 99F. The facility needs to ensure hot water temperatures are between 105 F and 116F. |
|
18
|
0.50
|
Drinking fountains clean, good repair |
No |
No
|
No |
.1314 (a) Drinking fountains shall be kept clean and in good repair. Observed white/blue color line of hard water buildup in water fountains at memory care. Need deep cleaning and keep clean. |
|
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 has a little kit on site and not the procedure of hot to handle such an event. Diarrhea and vomiting cleaning poster provided at the time of inspection. |