| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
8
|
2
|
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 spa room shower stalls with black grout. Clean these areas better.
Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b) Observed several pitted areas around handsinks. Many handsinks need better cleaning in staff areas. Replace broken or missing splash guards. Keep clean items out of splash zone of hand sinks
Handwashing sinks shall be accessible to all areas where personnel may be exposed to bodily excretions or secretions. 15A NCAC 18A .1312 (d). Observed blocked hand sinks in 2 soiled utility rooms. Keep sinks accessible. 2 hand sinks contained garbage cans and dirty bowl/utensils. |
|
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). In shower rooms disinfectant using was Vital Oxide. Labeling stated it was a food contact surface sanitizer with a 9:1 dilution. Documentation located said to be used as a disinfectant there should be a 5:1 water to product ratio. Make sure the dispensing machine is calibrated for the correct ratio, get proper labels and train staff on importance of contact time as your kill step. |
|
15
|
2
|
Approved water supply, no cross-connections |
No |
No
|
No |
Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d). Observed no backflow preventer on shower wand in spa room. Observed no air gap between discharge pipes and trough for washing machines. |
|
22
|
1
|
Solid waste disposed of frequently, no insect breeding or nuisance |
No |
No
|
No |
All solid wastes shall be disposed of with sufficient frequency and in such a manner as to prevent insect breeding or public health nuisances. 15A NCAC 18A .1316 (d). Observed dumpster without drainplug. Get rid of old items stacked around shed. Many have been there for quite some time and are holding stagnant water. |
|
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 a couple of storage rooms where misc. items were dumped in there. Clean and organize all non-resident areas.
Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a). Observed microwave and other PT items stored under hand sink in PT area. |
|
30
|
1
|
Medication carts clean, sharps containers affixed, food and utensils handled properly |
No |
No
|
No |
Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c). Observed lips exposed on drinking cups on med carts. Protect cups from contamination |
|
34
|
1
|
Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately |
No |
No
|
No |
Laundry areas and equipment shall be kept clean. 15A NCAC 18A .1319 (b) and .1312 (a). Observed laundry area needs cleaning. Folding tables with personal items that hadn't been moved or cleaned around in some time. Several carts with dust/debris. |
|
35
|
0.50
|
Patient contact items in good repair, properly stored, cleaned and disinfected |
No |
No
|
No |
Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c). Observed rollers and other beauty shop items need cleaning including chair backs. PT bench with tear. PT area had no disinfectant available. |
|
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 cabinets and shelves in nourishment room need cleaning |