| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
3
|
1
|
Walls and ceilings cleanable, clean, good repair |
No |
No
|
No |
Observed walls throughout facility in hallway, residents room, resident bathroom and storage room in need of touch-up paint. Touch-up paint throughout facility. Recommend sanding down front entrance door between lobby area and hallway area and repaint doors. Tightly secure and seal loose wall paper on 100 hall or just remove wall paper and repaint. Secure hand washing sink to wall in 212. Monitor ceiling in clean linen closet on 200 hall and ceiling in front of nourishment station on 100 hall and repair any roof leaks or wrap ventilation duct work. Tightly secure loose cove base moulding in 216 and 101. Repair wall behind bed in room 222 and lower section of wall in 121 and repaint. Clean window covering in room 224. Clean wall in room 122 beside bed A. Re-apply sealant/varnish on resident bathrooms doors which sealant/varnish is wearing off. Keep all walls and ceilings clean and in good repair. 15A NCC 18A .1310. |
|
5
|
1
|
Ambient air temperature 65 to 85 F, equipment clean |
No |
No
|
No |
Observed some light dust on ceiling ventilation in hallway, lobby area and bathrooms within resident room. Clean/dust ceiling ventilation. Observed debris present behind covering on heating and cooling unit. Remove covers from heating and cooling unit and clean debris from units. Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). |
|
10
|
0.50
|
Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected |
No |
No
|
No |
Observed bedpans and urinals not properly labeled throughout in resident rooms on both 100 and 200 halls. Label bedpans and urinals with residents name and date items were provided. Observed path to bedpan lug and spray arms obstructed in bio hazard closet. Keep pathway clear to bedpan lug and spray arms in bio hazard rooms so bedpans and urinals can be emptied, clean and disinfected in bio hazard rooms.Where bedpans are cleaned in patient/resident rooms, bedpan cleaning facilities shall consist of a water closet with bedpan lugs or spray arms. 15A NCAC 18A .1312 (c).Label all disposable bed pans and urinals with the residents/patients name and date. 15A NCAC 18A .1312 (c). |
|
23
|
1
|
Medical wastes handled and disposed of properly |
No |
No
|
No |
Observed sharps container over flowing with needles in med room on 200 hall. Close and replace sharps containers when full!All medical waste shall be handled and disposed of as required in 15A NCAC 13B .1200 Medical Waste Management. |
|
28
|
1
|
Adequate storage, area clean, items properly stored |
No |
No
|
No |
Observed cases of paper work stored on the floor in nurse training room storage room and beauty shop/storage room. Provide additional shelving or dunage rack to store items off the floor. Observed wheel chairs and jerry chairs stored outside of back door to facility. Store unused wheel chairs and jerry chairs in outside storage building. Provide an additional storage building if needed. 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). |
|
30
|
2
|
Medication carts clean, sharps containers affixed, food and utensils handled properly |
No |
No
|
No |
Observed single service articles(pill cup and water cups) not properly stored on med carts. Observed pill crusher and base of drawers on med carts soiled. Store pill cups and water cups in a zip loc bag or enclosed plastic container. If storing in plastic container on top of carts; minimize the amount of cups placed in containers. THOROUGHLY CLEAN PILL CRUSHERS ON MED CARTS! Clean base of drawers on med carts. Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c). Unused medication cups shall be kept covered or inverted. 15A NCAC 18A .1318 (c). |
|
32
|
1
|
Furniture clean and in good repair. Mattresses clean, dry, odor free |
No |
No
|
No |
Repaint or restain foot boards and head boards on resident beds throughout facility. Repaint or restains night stands in resident rooms throughout where needed. Repair closet door in 212. Observed loose and missing laminate on closet door and closet fixtures in rooms. Tightly secure loose laminate on closet door/closet fixture, replace missing laminate or paint area where laminate is missing. Clean out night stand dresser drawer in room 122. Clean chair in room 105.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). |
|
35
|
0.50
|
Patient contact items in good repair, properly stored, cleaned and disinfected |
No |
No
|
No |
Observed damaged wheel chair seat on wheel chair in 200 hall common shower. Replace damaged seat in wheel chair or replace wheel chairs. Observed patient contact items(bandages, wound care items, gloves) not properly stored in resident rooms on television shelving between resident closet. Clean and organize area where patient contact items are stored. Observed bed wedges/bed items stored on the floor in storage rooms. Store patient contact items off the floor. Patient contact items shall be kept clean,in good repair and stored to prevent contamination. 15A NCAC 18A .1319 (c). |
|
40
|
1
|
Food brought by employees or visitors handled properly |
No |
No
|
No |
Observed food in nourishment refrigeration unit on 200 hall not properly labeled with name and date. Label resident food and employee food with name and date food was brought into facility. Observed employee food stored above medication in refrigeration unit in nurse training room. Do not store employee food products in med refrigeration unit. 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). |