| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
2
|
1
|
Floors clean, carpet clean, dry, odor free |
No |
No
|
No |
Repeat Non-Compliance: Observed floors in need of general cleaning and repairing cracks in dinning hall, resident rooms and mis. rooms throughout. **Keep all flooring clean. 15A NCAC 18A .1309 (a). |
|
3
|
1
|
Walls and ceilings cleanable, clean, good repair |
No |
No
|
No |
Repeat Non Compliance: Walls to have dents, build up residue in bathrooms, blood stain in room 804, peeling wall paper, holes in need or repatching /repairing/cleaning. Ceilings to have cracked surfaces throughout, with a leak in corner of mens staff restroom. All floors walls and ceilings in need of general attention to cleanliness. **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 soiled shower chairs in spa's throughout in need of adequate cleaning. Observed shower pad in therapy hall spa torn in multiple places in need of repair. Repeat Non-Compliance: Obserrved shower curtains throughout spas with residue build up on bottom half of curtains in need of cleaning. Observed green linen storage container soiled on second shelf in need of cleaning. Observed broken plastic chair in therapy bathroom in need of repair or replaced. **Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).Repeate Non-Compliance: Observed toilet chair stained in room 910, toilet seat in need of repair in 900 spa, loose toilet seat in room 412** Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). |
|
13
|
1
|
Lavatory and bathing hot water between 100 and 116 F |
No |
No
|
No |
Observed hot water reaching over 116 F limit at sinks and bathrooms throughout facility. Temperatures ranged from 118 - 120 F. Water shall be tempered down to 100 - 116 F range. **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). |
|
14
|
1
|
Disinfectant accessible, properly used |
No |
No
|
No |
Observed multiple disinfectants locked in cabinets, not accessible throughout facility. Where residents are bathing, disifectant shall be accessible at all times. **A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). |
|
28
|
0.50
|
Adequate storage, area clean, items properly stored |
No |
No
|
No |
Observed mulitple storage rooms throughout facility with overloaded resident items stacked together enabling proper cleaning. Items shall be orgainized in fashion for proper cleaning process. **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 items stored under sink in gym therapy room in need of relocation. **Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a).Observed patient contact items stored on floor throughout facility in need of placing at minimum height requirement. **All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). |
|
30
|
1
|
Medication carts clean, sharps containers affixed, food and utensils handled properly |
No |
No
|
No |
Repeat Non-Compliance: Observed med cart collecting residue in drawer. Improvement made from last inspection. **Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c). |
|
32
|
1
|
Furniture clean and in good repair. Mattresses clean, dry, odor free |
No |
No
|
No |
Repeat Non-Compliance: Observed several torn, rippend, mattresses in rooms 804, 910, 500 in need of replacement. Repeat Non-Compliance: Observed ripped pillows throughout facility in need of replacement. **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 heavy staining of comforters, linens, pillow cases, mattress pads, throughout facility that need to be washed when soiled, or replaced. **Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). |
|
40
|
0.50
|
Food brought by employees or visitors handled properly |
No |
No
|
No |
Observed several items brought from home stored in front entrance nourishment room unlabeled. **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). |