| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
3
|
2
|
Walls and ceilings cleanable, clean, good repair |
No |
No
|
No |
Observed peeling wall paper and wall damage throughout building in hallways, activity rooms, resident rooms, nourishment and med rooms, and dining rooms. Observed hole in the wall of room 402, behind the bed in 109, and holes in the wall of 309. Observed foam tape in need of removal from wall in 100 hall. Observed door damage in 100 spa. Observed wall damage in the bathroom of 302. Observed missing window sill in room 809. Observed loose baseboards and loose FRP board in several areas throughout.
**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 Observed tile missing in 100 hall spa and damaged tiles in various areas of other spa bathrooms. Observed missing grout in shower of 505 and cracked tiles in shower of 705. Observed shower head in need of cleaning in 505 and 705. Observed cleaning needed on the bottom of shower chair in 900 hall spa. Observed debris on underside of shower table and mat in 100 and 700 spa. Observed caulking needed around sink in 901. Observed cracked sink bowl in room 402. Observed tub and shower chairs in need of cleaning and pink and black build-up in grout in spark unit. Observed toilet chair bowl with urine in 700 hall spa. Observed chipped tub in 100 spa. **Keep all bathing equipment, toilet equipment, and hand washing facilities clean and in good repair. 15A NCAC 18A .1312 (a), (b), and (f). |
|
9
|
1
|
Toilet rooms free of storage, hand wash signs posted |
No |
No
|
No |
REPEAT Observed chairs being stored in restroom 109, 103, and 302.
**Toilet rooms shall not be used for storage. See rule .1312 (b). |
|
14
|
1
|
Disinfectant accessible, properly used |
No |
No
|
No |
Through discussion, observed facility wiping spa tubs with a disinfectant. Manufacturers procedures must be followed.
**The manufacturer's instructions shall be followed for cleaning equipment with pumps. See rule .1312 (f). |
|
18
|
1
|
Drinking utensils properly handled |
No |
No
|
No |
REPEAT Observed unlabeled water pitcher in room 809.
**Label all disposable water pitchers with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a). |
|
28
|
1
|
Adequate storage, area clean, items properly stored |
No |
No
|
No |
REPEAT Observed toileting items being stored on the floor in the med-prep supply room. Observed storage under the sink in the 100 hall med room. Observed manipulatives being stored on the floor in the spark storage closet and gowns and face masks on the floor of the 200 hall storage closet. Observed chemicals being stored with gloves in 700 spa. Observed water cups being stored on the floor in central supply. Observed disinfectant wipes being stored over patient contact items in rehab storage closet. **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). **Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a). |
|
32
|
2
|
Furniture clean and in good repair. Mattresses clean, dry, odor free |
No |
No
|
No |
REPEAT Observed damaged laminate on armours in rooms 109, 402, and 302. Observed damaged table legs in spark unit dining area, damaged bedside table in 801, and bedside drawer stuck in 505. Observed cleaning needed in dressers throughout. Observed drawers and cabinets in need of cleaning throughout soiled utility, nourishment, and med rooms. Observed damaged cabinet and end table in 901. Observed stained curtain in rooms 409 and 402. Observed shower curtains in spa bathrooms with build-up on the bottom edges. Observed chair damage and bed table damage in 103. Observed torn and stained mattress in 402 and ripped mattress in 705. Observed cleaning needed on bed remotes.**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 |
REPEAT Observed debris in mattress in 103 and 201. Observed soiled linen unlabeled in rehab room. Observed soiled sheet and bed pad that had been made as clean in 309. Observed debris in bed and stained sheet in 705.
**Soiled laundry shall be handled and stored separately from clean laundry using separate cleanable carts or bags. 15A NCAC 18A .1319 (b).
Provide record of sanitization of comingled laundry. Observed no proof of sanitization on site today. |
|
34
|
1
|
Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately |
No |
No
|
No |
Observed clean linen being stored under the sink in room 505. Observed clean linen stored with other supplies in 700 hall clean supply, in rehab room cabinet, and in spark spa cabinet. Observed clean linen covers used to cover linen carts in hallways made of mesh where contamination is still possible, observed a stained linen on one of these carts with coffee stained on the mesh cover and the linen below. Observed vinyl linen covers with large holes being used to cover linen in spark unit.
**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). |
|
36
|
1
|
Approved utensils and equipment, cleaned and sanitized |
No |
No
|
No |
Observed cleaning needed in refrigerators throughout building. Observed nurse state that med cart water pitchers are cleaned in the nourishment rooms with hand soap. EHS explained that water pitchers need to be taken to the kitchen daily to be properly sanitized.
**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). |