The wall above room 104 has a crack in it that needs repaired.- Walls shall be clean and in good repair.
1.0
5.
In multiple rooms the air conditioning units have dust buildup in the filters and need to be cleaned.- Ventilation equipment shall be clean and in good repair.
0.5
32.
Multiple dressers had some handles missing from them and need repaired. The cabinet in the rec room needs repaired. The chairs in the living area need to be cleaned.- Furnishings shall be clean and in good repair.
0.5
General Comments
Due to COVID 19, Please follow CDC guidelines regarding social distancing, quarantine, and disinfecting. NOTE: Memory Care area was not visited due to COVID-19 infections and that area being the quarantine area.
In memory care community bathroom, caulk was missing in shower wall corners...Walls shall be maintained in good repair...Replace the missing caulk where needed.
0.0
5.
Wall HVAC units in Rooms #203, 208, beauty salon were dusty. Ceiling vent grates in SCU nurse`s station bathroom, laundry room, janitor`s room were also dusty...Ventilation fixtures shall be maintained clean...Increase cleaning frequency of fixtures above.
1.0
13.
Hot water at handsinks throughout facility was 120-124F (in resident rooms inspected, memory care areas, activity room, soiled uteility room, laundry and hall bathroom sinks)...Handsink and bathing hot water shall be between 100F and 116F...Adjust hot water to 100 to 116F.
1.0
30.
Some medication carts had old packaging material, one stray pill, old stickers and other debris at bottoms of drawers. Exteriors of some carts (near trash bins) were soiled. Observed one unsecured red sharps container leaning against wall on top of hand railing above med carts (not attached). On one cart, disposable spoons were stored with food contact sides up...Medication carts shall be maintained clean. Sharps containers on carts shall be affixed or secured to prevent spillage, disposable utensils on carts shall be protected from contamination...
medication carts shall be affixed or secured to prevent spillage...Increase cleaning frequency of med carts, secure sharps container to med cart and store disposable spoons with handles up.
1.0
32.
Surfaces under chair seat cushion in common areas (memory care, living room, etc.) had some debris, soil and/or were stained. Some vinyl chair arms were worn...All furniture, bedding, and furnishings shall be maintained clean and in good repair...Clean or replace (if needed) furniture stated above.
1.0
35.
In memory care supply room and in SCU nurse`s station bathroom, many boxes of disposable gloves and diapers/underwear were on floor...All patient care or consumable items shall be stored at least eight inches above the floor to prevent water contamination...Store items above 8 inches above floor.
0.5
General Comments
DISCUSSION REGARDING BACK UP WATER SUPPLY PLAN: Ensure your back up water supply plan encludes the following information: The local health department shall be immediately notified if the primary water supply is interrupted for more than four hours. Each institution shall have a plan to obtain a backup water supply in the event that the water supply is lost for more than four hours. The backup water supply plan shall provide for two liters of water per day per person for drinking. The backup water supply plan shall include a plan for either relocating residents or providing an alternative source of water for essential functions such as food preparation, hand washing, bathing, cleaning, dishwashing, laundry and disposal of bodily waste. The amount of water provided for uses other than drinking may be reduced if the plan includes alternatives for water use for services such as laundry and dishwashing. If an assessment determines that tap water is not to be used for drinking, sources shall be prominently labeled or hooded to restrict use and potable water shall be provided...>>>Due to COVID 19, Please follow current CDC guidelines regarding social distancing, quarantine, and disinfecting.
Vents need to be cleaned in Rooms 109 and the memory care unit sitting/dining area, the heating and cooling unit in the salon/resident laundry needs wiping down due to dust/black residue. Ventilation equipment shall be kept clean and in good repair. Change/clean vents and keep units clean.
0.0
8.
The bathroom fixtures in Rooms 109, 302 and 405 were dusty and had a build up of debris; the rubber seal on the shower floor was partially detached in Room 302. Fixtures and furnishings shall be kept clean and in good repair. Administrator had bathrooms cleaned.
1.0
16.
The agreement the facility has with Sysco states that they cannot be their primary supplier for water in case of an emergency/natural disaster. Obtain another supplier and have a clear plan for relocation if an additional back up water supply agreement cannot be secured.
0.0
32.
Some handles were missing from the tv console in the main sitting room; stains were under seat cushions in the memory care unit foyer/entry area as well as sitting/dining room; in addition the mattresses were stain and/or torn in Rooms 109 and 302. All furniture, blinds, draperies, shades, mattresses and other furnishings shall be kept clean and in good repair. Administrator has handles and will have them put back on; furniture as well as new mattresses have been ordered - some is already on site.
1.0
33.
The sheets were stained in Room 109 and a hair on the pillow case in Room 409 (rooms are not in use). Clean bed linen shall be in good repair and changed when soiled. The administrator had staff change the sheets.
1.0
35.
Boxes and a tote of pillows were being stored on the floor of the clean linen room. A container of oxygen tubing/supplies was being stored on the floor of the nourishment room. There were strands of hair left in one of the brushes in the hair salon. Patient contact items shall be stored at least 8 inches above the floor; patient contact items such as brushes, rollers, and other hair salon items shall be cleaned and disinfected after each use. The administrator had staff members put the pillows and oxygen supplies on shelves and made a note to speak with hair stylist about supplies.
0.5
General Comments
The janitor's closet, visitor and staff bathrooms, spa bathroom, medical records rooms, nourishment station, physical therapy, chapel, hair salon, memory care unit - dining/sitting room, boiler room, electrical room and Rooms 109, 203, 302 and 409 as well as perimeter and dumpster areas were inspected.
Inspection led by Jamie Phelps
*Melodee Wallace Johnson - Melodee.Johnson@wakegov.com - 919.609.1783*
.1309 (a) Boxes and other items stored on floors of closets, medicine rooms and other areas throughout the facility. All floors in intensive care units, bathrooms, showers, hydrotherapy areas, operating rooms, soiled utility rooms
and laundry areas shall be of smooth, non-absorbent materials and so constructed as to be easy to clean. Floors shall
be free of obstacles to cleaning, and shall be kept clean and in good repair. Carpeting shall be maintained clean,
odor free, dry and in good repair. Store items on shelves or rolling carts.
0.0
8.
.1312 (a) Sink drain plug for the hand sink in the laundry room not functioning properly and sink is plugged. All institutions shall be provided with toilet, handwashing, and bathing facilities that are conveniently located
and readily accessible to residents and staff. These facilities, and laundry facilities when provided, shall be kept
clean and in good repair. Repair sink drain.
0.0
9.
.1312 (b) Several shelving units in employee bathroom connected to the medicine room in the memory care hallway with toiletry items, boxes of gloves and several other items. Toilet facilities shall comply with the requirements of the state agency licensing the facility. Toilet rooms shall
not be used for storage. Remove items in bathroom.
0.5
13.
.1312 (e) Hand sink in bath/shower room on main hall 119F. Water heating facilities shall provide hot water within the temperature range of 100 degrees F to 116 degrees F at all lavatories and bathing facilities. Make necessary adjustments and check all sinks routinely.
1.0
28.
.1318 (a) Table and cabinet doors stored in soiled linen room in memory care hallway. Employee states that they are there to keep. Single use foam cups stored on floor in the mop sink closet with chemicals in the main hallway janitor closet. Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture and supplies,
and kept clean. All patient care or consumable items shall be stored at least eight inches above the floor to prevent
water contamination from cleaning floors and shall not be stored below exposed sewer lines.
0.5
32.
.1319 (a) Table with coating peeling and almost completely removed in soiled linen room in the memory care hall. Employee states that it is there to keep. Small tear in chair in the hallway of the memory care area. All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other
furnishings in institutions shall be kept clean and in good repair. Replace/repair necessary items.
1.0
36.
.1320 (a) Employee to go cup stored on top of paper towel bundles in janitor closet in the main hallway. Boxes of foam cups stored directly on the floor in janitor closet in the main hallway with the mop sink and chemical storage. All food service equipment and utensils used in institutions for preparing meals for 13 or more people shall
comply with the requirements of "Rules Governing the Sanitation of Restaurants and Other Foodhandling
Establishments" 15A NCAC 18A .2600. Store items at least 6 inches above the floor and protect from contamination.
0.0
42.
.1323 (a) Vanilla shake cartons sitting on top of each other and not in ice on a medicine cart in medicine room of memory care hallway at 44-49F. All food while being stored, prepared, transported, displayed, and served, shall be protected from contamination.
All perishable foods shall be stored at temperatures which will protect against spoilage. All potentially hazardous
food shall be maintained at safe temperatures (45 degrees F. or below, or 140 degrees F. or above) except during
necessary periods of preparation and serving. Items shall be covered in ice to maintain temperature or in refrigeration.
2.0
General Comments
Due to COVID 19, Please follow CDC guidelines regarding social distancing, quarantine, and disinfecting.
.1309- Floor is worn in the memory care dining room. Floors shall be in good repair.
0.0
2.
.1309-Floor has several black wheel chair tracks in the memory care dining room. Floor shall be kept clean.
0.0
5.
.3111-Observed several HAVC vents which need cleaning: Rooms 204,101,110,402,406 and memory care dining room. Ventilation equipment shall be kept clean. Repeat
2.0
8.
.1312- Stained shower curtain in room 208. Fixtures and furnishings shall be kept clean and in good repair.
0.0
13.
.1312-Hot water at the hand sinks is between 122-117F in rooms 105, 104, 110, 202, 302, 402, therapy restroom, memory care bathing room, living area and in the memory care dining room. Water heating facilities shall provide hot water within the temperature range of 100F to 116F. All lavatories and bathing facilities. The hot water heater was adjusted, during the inspection.
1.0
32.
Stained chair in memory care dining room, room 202 and room 310. Mattress cover is torn and stained in room 402. Missing a hinge in wardrobe closet in room 208. Furniture shall be clean and in good repair.
1.0
34.
.1319- Unlabeled soiled linen carts in the laundry room. Carts used for soiled laundry shall be labeled for soiled laundry use only.
1.0
35.
.1319- Storing breathing tubes in nourishment station in 400 hall, disposable gloves in the laundry room, adult disposable underwear in the outside storage shed, disposable underwear in the memory supply closet on the floor. All patient care shall be stored at least eight inches above the floor to prevent water contamination from cleaning floors.
0.5
43.
1323- Refrigeration unit in nurses station in 100 hall is 46F. Keep all refrigeration units at 45F and below.
Observed Room 203 is very dimly lit and needs a brighter bulb. Lighting throughout facility shall be at least 10-foot-candles of intensity. Replace bulb with a brighter bulb. [Repeat]
2.0
5.
Observed several air conditioning vents which need cleaning: Rooms 304, 307. 202 One side of AC vent missing. Air filters in all rooms that were checked were soiled. [Repeat)
2.0
8.
Observed fecal matter on toilet seat and/or gray portable potty chair as evidenced in rooms:
Room 202 - observed dried urine on the toilet seat. - clean immediately - gray potty chair has dark debris in seat corners - clean immediately
Room 309 - Broken toilet handle (cannot flush toilet) and toilet running constantly - feces on toilet seat - in need of immediate repair.
Shared bath - clean toilet - feces left in bowl - ring of residue in bowl - in need of immediate cleaning.
Shared bath - clean tub - tub has a pink - red residue in the basin around the drain - clean immediately.
Equipment shall be clean to sight and touch to preclude contamination as well as maintained and in good repair.
1.0
9.
Observed
0.0
14.
Observed absence of disinfectant stored in bathrooms. Ensure disinfectant for shared bathing facilities is readily accessible for use. (Repeat)
2.0
32.
Observed broken handles on cabinets in the Memory Care Nurses Station - cabinets over sink, over desk, and under counter fridge. Furniture shall remain in good repair. REPEAT
1.0
36.
Observed microwaves in common room areas all needed cleaning, especially the inside ceilings of units. Equipment shall be clean to sight and touch.
1.0
General Comments
This inspection was performed by Margaret A. Gunter
Lighting throughout, especially in patient`s bathing areas needs to be increased. Lighting throughout facility shall be at least 10-foot-candles of intensity.
1.0
5.
Air filters in all rooms that were checked were soiled.
1.0
8.
Shared bathrooms in 406 and 309 contained pink mold on shower heads. Better cleaning needed under shower seats throughout. Holes where toilet paper holder is missing observed in shared bathroom of 207. Toilet facilities shall be clean and in good repair.
2.0
14.
Ensure disinfectant for shared bathing facilities is readily accessible for use.
1.0
32.
Vacuuming underneath chair cushions in common areas is needed. Closet doors are in bad repair throughout facility. Knobs missing closet in room 304. Furniture items shall remain in good repair.
Paint chipping in dining room and baseboard missing in room 310 bathroom. Wallpaper is loose on wall outside dining area.
0.0
4.
Lighting in room 405 bathroom below 10 foot candles. Lighting throughout facility must be at least 10 foot candles. Repair light fixtures.
0.0
5.
Air filters in all rooms that were checked were soiled.
1.0
8.
In shared bathroom of 404 and 405 pink mold found on shower heads. Bedside commode in shared bathroom 306 and 304 contained rust as well as a loose escutcheon plate and loose toilet paper holder. Repair all items.
1.0
16.
Facility does not have a backup water supply plan. Repeat Violation. Each institution shall have a plan to obtain a backup water supply plan in the event that the water supply is lost for more than 4 hours. Plan shall provide for two liters of water per day per person for drinking. Backup Water Supply Plan guidance was left with operator.
2.0
30.
Cups were overstacked on 1 out of 5 medication carts observed. Avoid overstacking. Clean gloves found on top of sharps container. Nurse moved gloves.
0.0
32.
Vacuuming underneath chair cushions in common areas is needed. Dresser drawer is broken in room 102. Chair legs are worn in room 304. Examination bed in doctor`s office is torn. Furniture items shall remain in good repair.
1.0
33.
Mattress cover in room 102 was stained. Linen must be changed when soiled.
0.0
34.
No way to verify disinfectant concentration. Send readout from servicing manufacturer to Johanna Hill.
0.0
36.
Microwave in common area needs cleaning.
0.0
General Comments
Water temperature observed at 100 degrees F. Replace expired syringes. Rooms checked: 102, 104, 404, 405, 306, 310, and 304.
Handwashing sign missing in the bathroom across from the entrance to the memory care unit next to the soiled utility room. Signs shall be posted in each toilet room directing employees to wash their hands before returning to work. Handwashing signs were given to the operator.
0.5
13.
Recorded hot water temperatures between 113.8 degrees F and 119.1 degrees F throughout facility. Room 106 and bathing facility handsink in the memory care unit had the two highest temperatures. This is a repeat violation but there has been improvement in getting the water temperature down. Would suggest trying to turn down the hot water heater just a little more. Water temperatures should be between 100 and 116 degrees F.
1.0
16.
Facility does not have a backup water supply plan. Repeat Violation. Each institution shall have a plan to obtain a backup water supply plan in the event that the water supply is lost for more than 4 hours. Plan shall provide for two liters of water per day per person for drinking. Backup Water Supply Plan guidance was left with operator.
Room 408 contained fecal build up on the toilet fixture. Hand sink in room 405 continuously leaks even when turned off. All plumbing fixtures are to be in good repair and cleaned.
1.0
13.
The hot water in the rooms ranged between 120 to 128 degrees F at all hand sinks in the facility. Water heating facilities must have a temperature that range from 100 to 116 degrees F at all lavatories and bathing facilities. This has been a repeat item on the last three inspections
2.0
16.
Back up water supply plan was not onsite. Provide a backup water supply plan by the next inspection. Back up water supply plan is a documented emergency plan put in place if the facility was to lose water.
0.0
21.
Dumpster`s enclosure contained buildup. Ensure that this area is better maintained
0.0
30.
Single service articles on the med cart were stacked high and was not properly protected from contamination. Keep single service cups stored below cart brim or stored in original plastic wrap to protect against contamination.
1.0
35.
Toilet tissue was stored on the floor in the proximity of the can wash located in the laundry room. Hair rollers in the beauty salon room contained hair and not a label to whom they belonged to. Ensure that patient contact items are stored in clean dry areas off the floor and stored protected from cross contamination of different patients. Hair rollers shall not be reused amongst residents.
0.5
General Comments
Inspector contact info : Dimitri Parker (919)868-2562
The wall paper in the activity room and conference room was peeling. In the shower room in the Alzheimer unit the paint is peeling on the wall. Clean the ceilings around the vents to remove the dust.
1.0
4.
Replace the blown light bulbs in the shower room on the independent hall. Replace the missing light bulbs in the storage closet in Alzheimer unit. Replace the blown light bulbs in shower room in the Alzheimer.
1.0
12.
In room 302 on the Alzheimer`s units did not have any hot water. The cold water was working. All Lavatories must have mixing faucet or tempered water.
1.5
13.
The hot water in the rooms ranged between 120 to 128 degrees F at all hand sinks in the facility. Water heating facilities must have a temperature that range from 100 to 116 degrees F at all lavatories and bathing facilities. This has been a repeat item on the last three inspections.
2.0
General Comments
4. Clean the light shields to remove the dead bugs. Clean the vents to remove the dust throughout the facility.
Repaint the damaged walls in the dinning room of the Alzheimer unit. The paint on the walls are peeling in many areas. The shoe molding needs to be replaced in room 309, 408. The paint is peeling in room 121. The popcorn ceilings throughout to remove the dust. Clean the floors and walls in activity rooms. The ceiling in the shower room on the Alzheimer unit is peeling and needs to be repaired.
1.0
4.
Replace the blown light bulbs in the laundry room. Replace the blown light bulbs in the clean linen room in the Alzheimer. Replace the blown lights in room 106 and 408.
1.0
5.
Clean the dust build-up in the janitor closet. Clean the vents in the activity rooms. Clean the vents in the living room. Clean the light shields to remove the sider webs.
1.0
12.
In the soiled linen room on the resident care side there was no soap in the soap dispenser. Reattach the hot and cold water faucet handles on the hand sink in the laundry room.
1.5
13.
In all the rooms check the water temperature ranged between 117.9 to 121.5 degrees F at all hand sinks in the facility. Water heating facilities must have a temperature that range from 100 to 116 degrees F at all lavatories and bathing facilities.
1.0
General Comments
8. Reattach the hand rails on the shower. There were some baby spiders observed on several hand rails.
Repaint the damaged walls dinning room of the Alzheimer unit. The paint on the walls are peeling in many areas. Repaint the walls in room 304, 401.The shoe molding needs to be replaced in rooms 203, 401 Address the dented walls in the Alzheimer unit.
1.0
5.
Clean the dust build-up in the janitor closet. Clean the vents in the activity rooms. Clean the vents in the living room.Clean the vents in the air conditioner units in the bedrooms. Replace the broken light fixture in the special care unit.
1.0
8.
Repair the leaking faucet in the nourishment center. There was a leaking faucet and shower head handle in room 304. Replace the broken soap handle in room 304. Tighten the loose toilet seats in room 105,406. Tighten up the loose toilet seats in the Bath Care unit of the Alzheimer unit.
1.0
30.
There was one medicine cart that was not locked in the Treatment room. Keep all medication carts locked at all times.
1.0
32.
Clean the stained seat covers on the special care unit side. There were several chairs that had many stains.
Stained and/or damaged flooring located in the both front hallway restrooms, rooms 404, and 205. Some floors were not easy to clean due to there being gaps/openings where the shower is located. Flooring needs to be address in order for it to be easy to clean.
1.0
3.
Repaint and/or address some of the scratched/damaged walls in the bathrooms and resident rooms. Baseboards were missing in rooms/bathrooms 403 and 308. Make sure that staff are cleaning the corner walls due to cobwebs found in some. Address the dented wall behind the door of the soiled utility room. The wall, around the hand sink, in the alzeheimer dining room needs to be repainted.
1.0
5.
Clean the dust build-up found on the ventilation units located in some restrooms and laundry room. Clean the dead bugs out of the light shields located in room 403.
1.0
8.
Tighten the loose toilet seat located in the hallway bah/shower room. Leaky faucets were found in rooms 303, 101, and 102. Must be in good repair.
1.0
13.
The hot water in the hallway shower/bath room was jumping all over the place. It would jump in between the temperatures of 99-131F. Water is to be consistently between 100-116F.
1.0
32.
Replace the stained chairs located in the specialty area's shower/bath room. Chairs are not water resistant. Replace with ones that are water resistant. Replace the blood stained mattress in room 308.
1.0
General Comments
2. Terrible urine odor coming from room 205. Continue to work on addressing this issue and room. 34. Stained linen foud inside of the clean linen closet, in the alzheimer area.
Repaint and/or address some of the scratched/damaged walls in the bathrooms and resident rooms. Peeling wallpaper in the hallway of the specialty unit. Clean the inside part of the handrails, in the hallway. Trash found in some of those areas.
1.0
5.
Clean the dead bugs inside of the light shields located in the hallway, TV room, Activity room, and Rear dining room. Clean the dust build-up on the ventilation units located in the front hallway women`s restroom and laundry room.
1.0
8.
Tighten the loose toilet seats found in the hallway bath/shower rooms. There was one toilet not flushing in the 300`s hallway. Must be in good repair.
1.0
13.
The hot water in resident rooms, were holding consistently in between 120-122F. Water, available to residents, must be beetween 100-116F. Tempered valve needs to be adjusted.
2.0
32.
Replace the stained chairs located in the specialty area`s shower/bath room. The chairs get washed/cleaned but it is not water resistant. Replace the chairs with ones that are water resistant if staff will continue to wash/clean them. The chair pads absorb the water and it stains and molds on the inside. Stained chair in room 404.
1.0
General Comments
4. Replace the blown light bulbs found in the laundry room. 33. Replace the stained pillowcase room 303. Had blood on it. (Rooms inspected; 101, 102, 204, 205, 301, 303, 404, 407, Activity room, TV room, shower rooms)
Light bulbs need to be replaced in a number of bedrooms, bathrooms, shower rooms, bath rooms, and activity rooms. Must be in good repair.
1.0
5.
Ventilation build-up found in bathrooms, laundry rooms, some resident rooms and hallways. Must be cleaned.
1.0
8.
The vinly flooring in some resident restrooms were in coming up around the shower or behind the handsinks. Need to be re-caulked. Burnt flooring in rm 309. Hole in the bathroom wall of rm 301. Tighten the loose toilet seat, for the hallway bath room, in the alzheimer unit. Seal up the peeling baseboard in the bathroom of rm 404. Over flowing toilet in rm 303. Must be in good repair. (Do not use chairs that are not water resistant in the shower/bath rooms.)
1.0
13.
The hot water, in the shower room, got up to 122F. Water, available to the residents, must be between 100-116F. Tempered valve needs to be adjusted.
1.0
17.
Build-up, around the drinking area, found on the the water fountains located in the hallway. Must be cleaned.
The carpet, in the television room(living room) was stained.
1.0
3.
The walls in the resident rooms, soiled linen rooms, and other storage rooms need to be repainted. Peeling wall paper was found in the hallway of the alzheimer unit.
1.0
5.
Ventilation build-up found in linen rooms, soiled linen rooms, and some of the resident rooms. Must be cleaned.
1.0
8.
The vinyl flooring in some of the bathrooms were either stained or peeling. The baseboards in the restroom of room 404 were missing. Re-caulk the hand sink at the hallway ladies restroom located at the front of the facility. The bottom of the toilet for room 101 needs to be cleaned and re-caulked.
1.0
17.
Build-up, around the drinking area, found on the water fountains located in the hallway. Must be clean.
1.0
25.
Make sure that family/friends of residents do not bring in pesticide chemicals for the resident room. Found a bug spray can inside of one resident's restroom. Make sure that the staff is doing a good job during the cleaning and checking on residents.
0.0
General Comments
Change out the blown light bulbs in parts of the facility.
the carpet in the TV room is stained; sweep the storage room floors, and clean the janitors room floors
1.0
3.
the wall paper in the TV room is peeling off the walls; several A/C units have moisture damage on the wall next to them ( cracked paint; peeling dry wall ); patch and paint the walls where needed
1.0
5.
clean the AC filters frequently; clean the light fixtures as needed ( dead insects )
1.0
8.
the vinyl flooring in several bathrooms has dark stains; the vinyl in 102 and 309 is damaged; the shower fixture in 401 has a small leak, and rust is forming on the fixture; caulk the sinks where needed
1.0
13.
the hot water at the hand sink in the new shower room reaches 135 F; keep the temperature at 100-116 F
1.0
35.
personal supplies in shared bathrooms need to be stored separately ( in baskets or divided cabinets, for example )
0.5
General Comments
GC # 14 : the new shower room still needs acabinet with cleaning solution and disinfectant spray ; GC # 34 : on 300 hall, a stack of clean linen is sitting on top of a cart ( risk of contamination ); GC # 32 : the cabinets in the new sitting area ave some minor damage like a missing door handle and a cracked door ; Note : only one room is still being reatd for bed bugs; room has been empty for several months
the carpet needs to be cleaned; floor wax is building up at some closet thresholds ( keep the closet doors open when the floors are being waxed, and wax the closet floors, too )
1.0
3.
the wall paper in the TV room is peeling off the walls; several A/C units have moisture damage on the wall next to them ( cracked paint; peeling dry wall ); paint the walls where needed
1.0
4.
increase lighting in the bathrooms to 10 foot candles ( recommend a fixture above the mirror to increase lighting at the sinks ); repair the light near 309, and clean the light shields where needed ( dead insects in the fixtures )
1.0
8.
repair commode in 105/107; re-grout the tile around the drain in the hallway bath
1.0
24.
facility is working on a bed bug problem
1.5
30.
the sharps containers are standing on top of med carts instead of being held securely in the brackets ( containers are too large for brackets )
1.0
35.
urinals need to e labeled with the patient name; personal supplies in shared bathrooms need to be stored separately ( baskets; divided cabinets ); clean the remaining cloth covered chair in the TV room
0.5
General Comments
Note : there are still bed bugs in one room; contact Dr Kim Jung at 715-2687 for a consultation; GC # 5 : clean the ceiling vent covers in the bathrooms ; Gc # 13 : the only hand sink with a hot water temperature above 116 F is in the laundry room; residents do not use this sink; temperature is 119 F ; GC # 12 : avoid bar soap at shared hand sinks ; GC # 17 : the right hand fountain on 100 hall is not working properly; Note : the hopper sink has run dry and sewer gas in filling the room; sinks and commodes need to be flushed occasionally to maintain the water level in the P-trap
THE WALL PAPER IN THE TV ROOM AND THE ACTIVITY ROOM ACROSS FROM IT IS STARTING TO PEEL OFF THE WALLS; THE PAINT UNDER SEVERAL A/C UNITS IS BREAKING OFF (MOISTURE DAMAGE) CLEAN THE SPARE BEHIND HANDRAILS, FOUND SPIDER WEBS IN CORNERS WHERE WALLS MEET CEILING. REPLACE TWO BROKEN WINDOWS (HALLWAY AND ROOM 408)
1.0
4.
INCREASE LIGHTING IN ALL BATHROOMS TO 10 FOOT CANDLES AT THE HANDSINK
1.0
5.
CLEAN THE A/C FILTERS
1.0
14.
A DISINFECTANT BATHROOM CLEANER IS IN USE, BUT IN ADDITION TO THIS A SEPARATE EPA REGISTERED HOSPITAL DISINFECTANT IS NEEDED
1.0
17.
REPAIR ONE FOUNTAIN ON 100 HALL
1.0
24.
THE FACILITY IS WORKING ON A BED BUG INFESTATION
1.5
28.
CLEAN AND ORGANIZE THE SOLID UTILITY ROOM NEAR 100 HALL
0.5
34.
RECOMMEND USING AN AUTOMATIC DISPENSING SYSTEM FOR THE WASHING MACHINGS. LAUNDRY SANITIZER IS AVAILABLE, BUT THERE IS NO WAY TO TES HOW MUCH BLEACH IS ACTUALLY IN A WACHING MACHINE; WIPE THE TOP OF THE PVC LINEN CART
1.0
General Comments
RECAULK COMMODES AS NEEDED. THE VINYL FLOORING IN SEVERAL BATHROOMS IS STAINED. LINEN IN ROOM 101 WAS SOILED. LABEL PERSONAL USE ITEMS LIKE URINALS AND COLLECTION CAPS.
