| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
3
|
1
|
Walls and ceilings cleanable, clean, good repair |
No |
No
|
No |
Repeat Non-Compliance: Observed poorly repaired ceilings in hallways and closets throughout facility. Observed damaged wall paper in hallways, some wallpaper had mold on backside. Observed damaged wall in R 14. Observed wall damage behind doors and lower areas of exterior walls.
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. |
|
8
|
1
|
Facilities conveniently located, clean and in good repair |
No |
No
|
No |
Observed tear in shower bed pad. Hair and debris below shower bed pad in shower rooms. Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
Observed sinks that need cabinets below wiped out. Repair damaged backsplashes, R 102. Recaulk backsplashes where caulking missing, dining room. Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b) |
|
9
|
1
|
Toilet rooms free of storage, hand wash signs posted |
No |
No
|
No |
Repeat non-compliance: Observed maintenance/general storage in converted resident rooms.
Toilet rooms shall not be used for storage. See rule .1312 (b). |
|
10
|
1
|
Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected |
No |
No
|
No |
Repeat non-compliance: Observed bedpans with no label in resident rooms throughout.
Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c). |
|
15
|
2
|
Approved water supply, no cross-connections |
No |
No
|
No |
Observed no backflow preventers on shower wands in baths, usually single occupancy rooms. Observed no backflow preventers on removable eye wash sprayers throughout.
Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d). |
|
18
|
2
|
Drinking utensils properly handled |
No |
No
|
No |
Repeat Non-Compliance: Observed disposable water pitchers labeled with room number only or not labeled at all throughout facility.
Label all disposable water pitchers with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a). |
|
28
|
0.50
|
Adequate storage, area clean, items properly stored |
No |
No
|
No |
Observed storage rooms need cleaning and organizing. Get rid of stuff not needed or in disrepair. Basins of garbage stashed in clean linen rooms and soiled utility rooms.
**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 paper towels stored below hand sink in room in R 705. Personal items stored on floor in R 312 Unused specimen vials stored at hand sink in soiled utility room.
** All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). |
|
32
|
2
|
Furniture clean and in good repair. Mattresses clean, dry, odor free |
No |
No
|
No |
Repeat Non-Compliance: Observed several damaged mattresses in resident rooms throughout facility.
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
|
2
|
Linen changed when soiled. Soiled linen handled properly |
No |
No
|
No |
Observed soiled linen carts not labeled as "soiled linen" throughout facility. Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b).
Observed sheets on several resident beds stained or torn. Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). |
|
34
|
1
|
Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately |
No |
No
|
No |
Observed clean linen and chemical storage intermingled in clean linen room on service hall. Clean linen cart covers in disrepair throughout building. Hallway linen carts soiled, put onto cleaning schedule.
**Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. 15A NCAC 18A .1319 (b). |
|
35
|
0.50
|
Patient contact items in good repair, properly stored, cleaned and disinfected |
No |
No
|
No |
Observed used skin contact (razors, deodorant, etc.) items in general storage in shower rooms. Dispose of used items after use or return to patient's room after bath.
** Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c). |