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| CDI=Corrected During Inspection | |
R=Repeat Violation | |
VR=Verification Required | |
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| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
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|---|
|
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 detail cleaning needed on flooring (underneath the beds throughout the facility- which include room 508, 500, 114, nourishment room in memory care). Keep flooring clean. |
|
5
|
0.50
|
Ventilation equipment clean, good repair |
No |
No
|
No |
.1311 (b) Ventilation equipment shall be kept clean and in good repair.- Observed AC filter throughout the facility need detail cleaning and keep clean. |
|
7
|
2
|
Facilities provided, accessible, clean, good repair |
No |
No
|
No |
REPEAT
.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 toilet/toilet chair seat need detail cleaning in spa 400 hall, Rehab restroom, 301, 500, 218 and 316. Keep clean. Observed rusted toilet chair in 316, 301, repair/replace needed. |
|
8
|
1
|
Toilet rooms free of storage, handwash signs posted |
No |
No
|
No |
REPEAT
.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed wheelchair, maintenance carts, walkers, stored in spa room in 400 hall. Remove items and only store bath related/permitted items. |
|
10
|
0
|
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 no paper towels and soap in the dispenser in med room hand washing sink. Ensure to provide all handwashing supplies at all hand sinks at all time. |
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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.- According to a housekeeper, the facility does not have clear knowledge of the contact time for chemical use for cleaning. Ensure to contact the company who supply the products, know and educate all cleaning staff about the contact time for effective and proper cleaning of the facility. |
|
17
|
1
|
Back-up water supply plan available and complete |
No |
No
|
No |
REPEAT
.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 the facility without/incomplete water back up supply plan. EHS emailed a checklist of the plan to an administrator and head of maintenance at the time of inspection. The facility will working on getting a complete plan. |
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