| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
8
|
1
|
Facilities conveniently located, clean and in good repair |
No |
No
|
No |
Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed two shower chairs with residue on two units (Repeat Non-Compliance). Observed Shower beds damaged on two units. Observed toilet chair in E27 with residue. Observed a loose toilet seat in the therapy restroom. |
|
11
|
1
|
Hand sinks used only for intended purpose |
No |
No
|
No |
Except for the stipulations stated in rule .1312 (d), handwashing sinks shall only be used for handwashing. 15A NCAC 18A .1312 (d). Staff advised they are collecting water in handwashing sinks for the med carts. All water for drinking must be obtained from the kitchen or from a water fountain. |
|
13
|
2
|
Lavatory and bathing hot water between 100 and 116 F |
No |
No
|
No |
Maintain the hot water at all resident accessible handwashing sinks and bathing facilities within the temperature range of 100°F to 116°F. 15A NCAC 18A .1312 (e). Observed hot water in a South Central Bathroom at 120 F. Hot water tempered back down to 114 F after prolonged use. (Repeat) |
|
14
|
1
|
Disinfectant accessible, properly used |
No |
No
|
No |
A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). Observed one central bath missing its disinfectant (Repeat, but observed improvement). |
|
17
|
1
|
Water fountains clean, good repair, properly regulated |
No |
No
|
No |
Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a). Observed two water fountains collecting pink and black residue. |
|
28
|
0.50
|
Adequate storage, area clean, items properly stored |
No |
No
|
No |
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). Observed some storage cabinets collecting debris and damaged. Activity, therapy, and pantries. Observed two custodial closets with chemicals stored above paper towels. Store chemicals below all other items. Observed coffee cups exposed to contamination in the Activity room. Keep the cups covered. Observed patient care items stored under sinks in a med room and in the therapy room. |
|
32
|
1
|
Furniture clean and in good repair. Mattresses clean, dry, odor free |
No |
No
|
No |
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). Observed several beds with damaged pillows. |
|
36
|
1
|
Approved utensils and equipment, cleaned and sanitized |
No |
No
|
No |
Non-food contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. See rule .1320 (c). Observed refrigerator gaskets with debris in activity and pantry areas. Observed ovens in the activity and pantry areas in need of cleaning. Observed a damaged crisper drawer in the refrigerator in the East Pantry
Activity kitchens or nutrition stations that are not approved to clean food service utensils and equipment shall return all food service utensils, equipment, and utensils not continuously subjected to high temperatures to the kitchen after each use to be washed, rinsed, and sanitized. 15A NCAC 18A .1320 (b). Staff in the therapy room advised they was the utensils in the kitchen in the 1 compartment sink. All used food service utensils and cookware must be returned to the kitchen for cleaning and sanitizing when the activity is completed. |
|
40
|
0.50
|
Food brought by employees or visitors handled properly |
No |
No
|
No |
Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply and shall be labeled with the name of the person to receive the food and the date the food was brought into the facility. 15A NCAC 18A .1321 (b). Observed staff and resident food comingled in the therapy room refrigerator. Food was not labeled. |