| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
3
|
1
|
Walls and ceilings cleanable, clean, good repair |
No |
No
|
No |
Repeat Non Compliance: Observed some areas with water stains. Visible repairs have been made. Quotes from FlexaCoat were seen. Continue to complete repairs. Improvement seen from previous inspection. Observed wall in South Nourishment room in disrepair from previous soap dispenser.**Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. |
|
8
|
2
|
Facilities conveniently located, clean and in good repair |
No |
No
|
No |
Repeat Non Compliance: Observed underside of shower chair rusted and soiled in room 266, 182, west shower chair. Observed slow drain sink in room 182. Observed eye wash in West shower hanging off wall. **Keep all hand washing facilities clean and in good repair. 15A NCAC 18A .1312 (b)**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 disinfectant not present in North shower room, and pulled and refilled when entering shower room in HA.Observed purple top disinfectant wipes not present in PT room at time of inspection. Correct wipes were provided before leaving PT room. **A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). |
|
24
|
1.50
|
Vermine excluded |
No |
No
|
No |
Repeat Non Compliance: Observed ants present in resident room #182 trash can, and in South shower room near foot cleaning equipment. Observed live mouse caught on glue board located in back room of laundry. **Effective measures shall be taken to keep flies, rodents, cockroaches, and other vermin out of the establishment and to prevent their breeding or presence on the premises. 15A NCAC 18A .1317 (a). |
|
28
|
1
|
Adequate storage, area clean, items properly stored |
No |
No
|
No |
Repeat Non Compliance: Observed pull ups, clothes, and other items stored on floor in residents closets. Rooms included, but not limited too: 266, 173, 182, Observed humidifier bottle stored on floor in oxygen room. Observed empty linen carts, shelving, and other items stored behind storage unit. Observed excessive equipment stored in West shower and wheel chairs stored outside under porch/covered area. **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).**All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). |
|
32
|
1
|
Furniture clean and in good repair. Mattresses clean, dry, odor free |
No |
No
|
No |
Repeat Non Compliance: Observed 2 small stains on furniture in library near west/north halls. Observed 1 stain on resident chair next to closet in room 173. **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).Improvement seen. |
|
33
|
1
|
Linen changed when soiled. Soiled linen handled properly |
No |
No
|
No |
Observed linen in need of cleaning in room 182. Keep all linen clean and in good repair. Observed extra bagged soiled linen on top of covered soiled linen trash can. Improvement seen with stained linen. **Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). |
|
35
|
0.50
|
Patient contact items in good repair, properly stored, cleaned and disinfected |
No |
No
|
No |
Observed shower cart with residue present in West shower room, with coat hangers touching the floor in laundry room. **Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).**Patient contact items that become contaminated during use shall be cleaned and disinfected after each use. 15A NCAC 18A .1319 (c). |