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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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|---|
|
5
|
0
|
Ventilation equipment clean, good repair |
No |
No
|
No |
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed dust on the ceiling vent in bathroom 73. AL. 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 chipped paint on a toilet adapter in AL room 73. Need repair or replace for smooth/easily cleanable surface. Keep clean and in good repair. |
|
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 towel at a hand washing sink at skill nursing in supply room. ENSURE ALL HAND WASHING SUPPLIES (SOAP AND PAPER TOWELS) ARE AVAILABLE AT ALL TIME. |
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11
|
2
|
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 a bathroom disinfectant bottle on top of a kitchen counter next to hand sink in skill nursing unit. Ensure to use a proper cleaning solution where is appropriate in accordance to the manufactures instructions. Observed cleaning cart with cleaning/disinfecting bottles with fade-out labeling, hard to see the cleaning instructions. Ensure to provide a new legible labeling one the bottles and provide training for all cleaning staff how to use chemicals in accordance with the manufacturer's instructions for an effective cleaning. |
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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. Observed the facility back up water supply plan without details of how the plan will be implemented in the event of lost water for more than 4 consecutive hours. EHS emailed staff a BACKUP WATER SUPPLY PLAN CHECKLIST. The facility will be working on getting details plan in place. |
|
51
|
0
|
Proper use of restriction, exclusion, and reporting |
No |
No
|
No |
.1324 (c) Institution employees shall comply with the requirements for exclusion from work and restriction due to communicable disease or illness required for food employees as set forth in Parts 2-201.12 and 2-201.13 of the Food Code incorporated by reference at 15A NCAC 18A .2650 as amended by 15A NCAC 18A .2652. NEW RULES. No Point Deduction. CDI- Employee Health Policy poster provided at the time of inspection. |
|
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. NEW RULES. No Point Deduction. CDI- Vomiting and Diarrheal clean up poster provided at the the time of inspection. |
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