Flooring in EVS basement storage room under/around mop sink was soiled. Flooring in stairwells was dusty/soiled...Flooring shall be kept clean...Increase floor cleaning frequency in areas above.
0.0
2.
Baseboard in EVS storage room was peeling/damaged. In regulated medical waste room, many small holes were in walls...Walls shall be maintained clean and in good repair...Repair wall baseboard and seal wall holes.
0.0
4.
No light fixture was in patient room #2231 bathroom shower, and lighting was very dim...Lighting shall be at least 10 foot candles at 30 inches above the floor in all areas...Increase lighting intensity in this bathroom shower.
0.0
5.
Ceiling vent grates in ED 24 and ED public bathroom and a few other areas were dusty...Ventilation equipment shall be kept clean...Increase vent grate cleaning frequency.
0.0
9.
Bedside commodes stored as clean in Rooms #4706, #3732, 3731, 4231 were soiled and/or had old tape and stickers on them (making surfaces hard to clean and disinfect properly). Hopper in Pre-Op (#1487) was soiled...Bedside commodes, hoppers, etc. shall be properly cleaned and disinfected...Increase detailed cleaning frequency of commodes and hopper.
0.5
10.
Soap was missing at handsinks in Room #2223A (also paper towels were not dispensing), #3276B, NP hallway public bathrooms, 4200 utility room by nurse`s station. Soap and paper towels were not available at handsink in Pre-Op clean linen storage room...Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices...Maintain adequate supply of soap and paper towels at all handsinks.
1.5
16.
Hot water at handsinks was 99F in Room #4706, 119-122F in public bathrooms in 3NP, 120F in 4200 public bathroom, 96F in ED24, 122F by PACU 31 & 32, 125F at Pre-Op nourishment station, 125F by Pre-Op 44 & 45...Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities...Provide hot water stated above at all handsinks.
1.5
38.
Several nutrition stations inspected had soiled microwave oven interiors, interior cabinets and shelves, and refrigerator interiors and exterior bottoms areas...Food service equipment and utensils shall be kept clean and in good repair...Increase cleaning frequency of equipment above.
0.5
General Comments
DISCUSSION: A sign shall be posted in each toilet room for employees directing them to wash their hands after each visit to the toilet room and before returning to work...Temperatures of potentially hazardous foods (time-temperature control for safety foods) in refrigerators must be 41F or less.
.1310; Soiled linen rooms in the fourth pavilion have holes in the wall where the shelf is screwed in. The paint on some of the walls on the fourth floor is chipping in the halls of the North Pavilion. Some of the ceiling tiles in the basement storage rooms have water damage or are cracked. Walls and ceilings shall be kept in good repair.
1.0
13.
.1312 (e); The shower in room 2703 was only able to reach 95F during the inspection. Water shall be tempered between 100F-116F at all lavatories and bathing facilities.
0.0
28.
1318 (a); A cabinet holding soda cans in a nourishment room on the 3rd floor of the North Pavilion was soiled with residue. Some single-service articles were stored with the food-contact surface face up or in containers that had food debris. The drawers underneath the ice machines in the nourishment rooms of the South Pavilion have water damage. Some of the fridges in the medication rooms have dust and debris on the bottom. Suitable storage for supplies shall be provided and clean.
0.5
32.
.1319 (a); Couches and chairs in two rooms on the fourth floor of the North Pavilion had tears in them and worn cushions. Patient furniture shall be kept clean and in good repair.
0.0
33.
.1319 (b); Fitted sheets over mattresses in a few rooms had small holes in them. A couple of sheets in a couple of the patient rooms and stored in the clean linen rooms have slight stains. Linen shall be kept in good repair.
1.0
General Comments
Due to COVID 19, Please follow CDC guidelines regarding social distancing, quarantine, and disinfecting.
Room 16 in ED section has tearing on wall and hole in the wall with dust accumulating inside of it. Room 9 (bathing room) has tearing on the wall surrounding soap dispenser. Patient care room 3233 is damaged on the corner of wall and is not easily cleanable. Dirty utility has holes in the wall near soap dispenser. Walls in several patient rooms have marks/scuffing due to equipment being scraped up against the wall and needs to be cleaned/repainted.
1.0
5.
One ventilation unit had buildup of dust in room 4241. Ventilation/air units shall be kept clean.
0.0
16.
Facility has a detailed emergency water supply plan on site stating that they will contact crystal springs during a water shortage emergency, but no letter is on hand from the supplier as confirmation. Facility will email EHS with letter from the supplier stating that 2 liters of water a day per person will be provided.
0.0
28.
Cabinets in third floor nourishment room where soda/drinks are being stored are heavily soiled and need cleaning. One door on these cabinets is loose / not closing properly and may need to be repaired. Storage spaces shall be kept clean and in adequate repair.
0.5
33.
.1319 (b); Room 16 has several tears/holes in bed linen. Room 3236A has tearing on pillow case. Room 4241 has staining on mattress. Linen shall be kept in good repair and clean.
1.0
General Comments
All handwashing sinks tested reached a maximum temperature between 100-116F. Sarah Black and Nicole Bailey participated in inspection.
Walls in rooms had marks on them due to equipment being scraped up against the wall and needs to be cleaned/repainted.
1.0
10.
Bedside commode in 5211 was soiled and rusty and needs to be cleaned or replaced if it cannot be cleaned. Check all toilet accessories for rust and soiled parts.
0.5
32.
Found multiple chairs in patient rooms that were worn and need to be replaced.
Dust air conditioning vents as needed. Clean light shields and elevator ceilings as needed to remove dust and dead insects.
1.0
9.
0 points; Equipment cannot be stored in bathing rooms. Find alternate storage location for 3rd floor bathroom storage room number 3238.
0.0
11.
0 points; Hand sinks shall be accessible and in good repair.
0.0
12.
Multiple hand sinks had no paper towels provided. Make sure all hand sinks have paper towels provided at all times.
1.5
16.
Repeat Violation-Back up water supply plan was onsite but incomplete. Ensure that the plan states that the Health department will be contacted within 4 hours in the event of a water outage, single service articles will be used for foodservice in the event of an outage, patients will be provided with 2 liters of drinking water per person per day.
1.0
32.
0 points; Repeat Violation-Replace stained chairs throughout establishment (improvement is noted from last inspection).
0.0
36.
Repeat Violation-Replace torn gaskets in refrigeration. Clean all microwaves more frequently.
1.0
General Comments
Patient contact and bulk patient contact storage must be on shelving that allows for cleaning underneath and be 8 inches off of the floor. Pallets are not approved shelving.
Janitor`s room, bathrooms and several storage rooms checked contained floor damage. All floors are to be in good repair and easily cleanable. Repair damaged floor areas throughout.
1.0
3.
Janitor rooms, bathrooms and several storage rooms checked contained wall and some ceiling damage. All walls and ceilings are to be in good repair and easily cleanable. Repair damaged walls and ceiling areas throughout.
1.0
4.
One blown light was in the soiled utility room located on the ED floor. Lighting is to be 10 ftcd throughout. Replace blown bulb as needed.
0.0
9.
{Repeat} Several toilet rooms checked were missing hand wash signs. All hand sinks in toilet rooms must be provided with wash signs
1.0
28.
Floor in one storage room checked contained dust and debris build up. Ensure that all floors are cleaned to a frequency that prevents build up.
0.0
32.
Arm chairs in room 5209 and 3206 contained damage along the arm rest area. Ensure that all furniture is in good repair so that fixtures are smooth and easily cleanable.
1.0
33.
Observed stained bed linen in room 5239. Glue was on sheet of bed stored on the first floor in a hallway. Linen is to be changed when soiled and handled properly.
0.0
36.
Nourishment room cabinets and microwave were soiled. Ensure that all equipment and cabinet areas are cleaned and maintained.
1.0
43.
Refrigerator unit in med room located on the third floor was missing a thermometer. Thermometer was installed in unit during the course of the inspection. Ensure that all refrigerator units contain thermometers.
0.0
General Comments
Back up water supply plan was onsite but incomplete. Ensure that the plan states that the Health department will be contacted within 4 hours in the event of a water outage, single service articles will be used for foodservice in the event of an outage, patients will be provided with 2 liters of drinking water per person per day. Ensure that all linen baskets are labeled accordingly. (If soiled then label laundry bin soiled). Ensure that all hand wash sinks are not slow draining or blocked off. Hand sinks shall be accessible and in good repair.
STORAGE ROOM FLOORS, FLOOR CORNERS, UNDER STORAGE RACKS, BEHIND NOURISHMNET FRIG UNITS, ICE MACHINES, HALLWAY AREAS, MORGUE AREA FLOORS, ETC IN NEED OF CLEANING
1.0
3.
RESTROOM WALLS, HALL WAY WALLS, STORAGE AREA WALLS WITH HOLES, PEALING WALL COVERING, ETC ALONG WITH LINT BUILD UP NEEDS CLEANING; CELING VENTS WITH BUILD UP ON CORNERS, AND AROUND CEILING PANELS; CELAN LIGHT FIXTURE INTERIORS
1.0
8.
SHOWER SEAT TORN, BEDSIDE TOLIET SEAT HINGES RUSTING, RECOMMEND CHECKING ALL FOR TEARS, REPLACE WITH SMOOTH, CLEANABLE NON-ABSORBANT SURFACES; REPLACE ICU WAITING ROOM FAUCET WITH PITTED FAUCET; LAB AREA HANDSINK, COUNTER, AND GENERAL AREA NEEDS SEVERE CLEANING....KEEP LAB UTENSILS, EQUIPMENT, AND OR SPECIMEN ITMES AWAY FROM HANDSINK AREA; CLEAN ALL HAND WASHING FAUCET BASES...SOAP RESIDUE OBESRVED ON BACK SIDE; REPAIR/REPLACE DAMAGED HAND SINK COUNTERS AND BACK SPLASH AT NURSES STATIONS, NOURISHMNET AREAS,
1.0
9.
ENSURE ALL HANDSINK AREAS HAVE HANDWASH SIGNS
0.5
17.
FIRST FLOOR WATER FOUNTAIN WITH PINK SLIME BUILD UP AROUND MOUTH PIECE...PROPERLY CLEAN AND DISINFECT
1.0
19.
ALL ICE MACHINES ARE IN NEED OF #7, #9, OR EQUAL DUAL CHECK VALVES....IF WATER SUPPLY LINES ARE SHARED WITH COFFEE MACHINES, ETC, ENSURE THOSE UNITS ARE PROTECTED ALSO
0.0
28.
GENERAL STORAGE AREA NEEDS THOROUGH CLEANING UNDER ALL RACKS/SHELVING SYSTEM
0.5
29.
MOP SINK ROOM AND MACHINE AREA FOR MOP HEAD CLEANING NEEDS THOROUGH CLEANING
0.5
35.
ICU BED RAILS OBSERVED BEING CLEANED, HOWEVER, BACKSIDE OF RAILS, HANDLES WERE NOT CLEANED...ADVISED STAFF, SURFACES RECLEANED/DISINFECTED. ALSO, BED RAIL CONTROLS NEED BETER CLEANING ALONG GROOVES AND SEAMS
0.5
36.
NOURISHMENT KITCHEN AREA CABINET INTERIORS, REFRIGERATORS, GASKETS, ETC NEED THOROUGH CLEANING
1.0
General Comments
LAB EQUIPMENT IN NEED OF A THOROUGH CLEANING, EXTREME BUILD UP ON SINKS, COUNTERS, HODDED WORK COUNTER AREAS, HANDLES, ETC.
FLOORS IN BIO HAZARD STORAGE, HALLWAYS, PROCEEDURE ROOMS, LAUNDRY STORAGE, NEED REPAIR AND CLEANING. SEVERAL FLOOR AREAS RIPPED, CRACKED...THESE AREAS ARE SLATED FOR REPAIR/DEMOLITION/RENOVATION
0.0
3.
WALL COVE BASES, DOOR BASES, DOOR JAMBS, IN BIO HAZARD STORAGE, HALLWAYS, PROCEEDURE ROOMS, LAUNDRY STORAGE, RECOVERY, RESTROOMS, NEED CLEANING AND REPAIR...THESE AREAS ARE SLATED FOR REPAIR/DEMOLITION/RENOVATION
0.0
21.
CLEANING NEEDED ON ALL TRASH CART AND CAN EXTERIORS AND INTERIORS, A FEW NEED REPLACING (GLAZING IS PEALING, UNITS CRACKED)
2.0
28.
SEVERAL STORAGE AREAS THROUGHOUT ED, CT, PR WITH PRODUCT ON THE FLOOR, UNDER SHELVES, PROPERLY STORE ON CLEAN RACKS
0.5
30.
SUPPLY CARTS NEED THOROUGH CLEANING, LOTS OF LIQUID RESIDUE AND TAPE RESIDUE PRESENT, REPAIR HANDLES
1.0
35.
MATTRESSES RIPPED/TORN, SHEETS WITH HOLES, PATIENT PROCEDURE TABLE MATS WITH HOLES AND TARES, IV POLES AND ANESHESIA POLES WITH RESIDUE, TAPE AND SPOTS,....REPLACE AND REPAIR AS NEEDED; BED FRAMES NEEDING CLEAING, HEAD WALLS NEED DUSTING
0.5
36.
NOURISHMENT KITCHEN AREA CABINET INTERIOS, REFRIGERATORS, GASKETS, ETC NEED THOROUGH CLEANING
1.0
General Comments
FRANCES BREEDLOVE AND LUCY SCHRUM PRESENT TODAY; CLEANING NEEDED ON RESTROOM VENTS, LAUNDRY VENTS, ED, ETC
keep all storage off the floor; the bottom shelf of storage racks needs to be high enough off the ground to allow for floor cleaning; sweep the storage rooms; replace pallets with dunnage racks; clean the floors of storage areas, nourishment stations, and janitors closets on the patient floors
0.5
General Comments
GC # 3 : the furniture in the patient rooms is leaving marks on the walls; paint as needed ; GC # 5 : dust the ceiling vents as needed ; GC # 34 : the hand sinks in the dirty linen rooms are blocked with storage like bags of dirty linen
one cluster of bathrooms on the 4th and 5th floor does not get a hot water temperature of 100-116 F at the hand sinks; temperature drops as low as 85 F
1.0
28.
keep all storage off the floor to allow for floor cleaning; sweep the storage rooms; replace pallets with dunnage racks; especially in the large general storage areas, the bottom shelf of each storage unit needs to be high enough to allow for floor cleaning; clean the linen rooms and other storage areas on the patient floors; do not use the tubs in staff lounges for storage; replace any broken wheels on storage racks
0.5
General Comments
GC # 14 : a separate disinfectant in a spray can is available but is only used for isolation units; the bathroom cleaner is a disinfectant cleaner ; GC # 43 : clean the refrigerators in the nourishment stations ; GC # 17 : adjust one fountain on the 5th floor ; GC # 3 : the walls need touch-up painting in some areas
keep all storage off the floor to allow for floor cleaning; sweep the storage rooms; replace pallets with dunnage racks; especially in the large general storage areas, pallets and racks need to be moved to clean the floors
1.0
33.
several privacy curtains needed to be changed ( stains )
1.0
General Comments
GC # 1,2,3 : the building is still undergoing remodelling; in the older sections, walls and floors need repairs; GC # 19 : ice machine in the nourishment station on 4th floor seams to have a leak
hot water at hand sinks in cancer center reaches 120 degrees F ; adjust hot water or use tempering valves for the hand sinks
1.0
17.
one fountain needed to be cleaned; one needs to be adjusted
1.0
General Comments
Note : do not block hand sinks in dirty utility rooms with storage ; GC # 1 : building is still under construction; some damaged floor tiles and worn carpet on 4th floor
