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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 |
|
|---|
|
3
|
1
|
Walls and ceilings cleanable, clean, good repair |
No |
No
|
No |
Observed severla ceiing leak throughout the facility (3rd floor medication storage, 2nd floor clean linen, staff lounge, AL room 352, a wall was being repaired from water damage in the 3rd floor dining room (from ice machine malfunction), and the walls and floor needed cleaning/repainting on the balcony in room 352.**Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. |
|
8
|
1
|
Facilities conveniently located, clean and in good repair |
No |
No
|
No |
Observed the soiled linen area has been moved to a new location in the Lower Level (hallway/pass through) and has no hand washing sink. Observed a staff member transfer soiled linen bags tot he storage area with bare hands (no gloves) and did not wash hands. **Install a hand washing sink in the new soiled linen storeage area.**Handwashing sinks shall be accessible to all areas where personnel may be exposed to bodily excretions or secretions. 15A NCAC 18A .1312 (d).Observed the hopper would not flush and was dirty in the biohazard room on 3rd floor, and the toilet was soiled in resident room AL 352, a soiled bedside comode bucket in the resident community shower room, a bedside comode was not cleaned in room 311.**Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). |
|
14
|
2
|
Disinfectant accessible, properly used |
No |
No
|
No |
Repeat Non-Compliance - Observed disifectant was not available in most residient community shower rooms.**A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).**Skin contact surfaces of all shared bathing equipment shall be cleaned with a detergent solution and then disinfected with an EPA registered hospital disinfectant between patient uses. 15A NCAC 18A .1312 (f). |
|
19
|
1
|
Ice protected, dispensed, equipment clean in good repair |
No |
No
|
No |
Observed the ice machine shoot with mildew in the 2nd floor dining room galley. The staff member stated that the snaitizer/germicidal wipes were used to clean the ice machine. **Only use sanitizer safe for food service.**Ice machines, buckets, other containers, and scoops shall be cleaned on a regular schedule such that they are kept free of scum, rust, mold or other contamination. 15A NCAC 18A .1314 (b). |
|
28
|
0.50
|
Adequate storage, area clean, items properly stored |
No |
No
|
No |
Observed a mattress was stored onthe floor in the 2nd floor storage closet, and isolation gowns were stored on the floor in 3rd floor supply closet.**Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a). |
|
32
|
1
|
Furniture clean and in good repair. Mattresses clean, dry, odor free |
No |
No
|
No |
Observed a dresser missing handles in room 270, a cushion on a chair with surface damage, and a couch with accumulated food debris under the cushions,**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. 15A NCAC 18A .1319 (a). |
|
33
|
1
|
Linen changed when soiled. Soiled linen handled properly |
No |
No
|
No |
Observed soiled sheets in room 311, and two pillow cases were soiled in room AL 365. **Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).NOTE: Observed the containers storing soiled linen was not labeled, and some bags were not labeled.The "soiled linen" label was faded and hard to read in 2nd floor soiled linen room. **Re-label the container. |
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