| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
3
|
2
|
Walls and ceilings cleanable, clean, good repair |
No |
No
|
No |
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed touch up needed to door frames throughout building. Observed stained ceiling tile in laundry room over large industrial washer. Per conversation with Head of Maintenance the stains are from an old leak. EHS advises facility to ensure no active leak is occurring and to repair/repaint over stained ceiling. REPEAT VIOLATION |
|
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 large tubs in all shared spa rooms checked during time of inspection with storage stored inside of them and in need of general detailed cleaning. Observed linen stored on the floor in disarray in shared spa room located on 900 hallway. Observed black build up inside of floor tiles located in shower in shared spa room located near small rehab gym. Observed build up under toilet lid in room 801.
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed heavy feces build up under toilet lid in room 116. Observed loose toilet seat in room 600. Observed staining under toilet lid in shared spa located on 300 hallway. EHS advises facility to increase cleaning frequency of bathing and toileting items throughout facility. |
|
9
|
1
|
Toilet rooms free of storage, hand wash signs posted |
No |
No
|
No |
Toilet rooms shall not be used for storage. See rule .1312 (b). Observed storage to include gloves, diapers, large bins, and linen stored in shared spa room located across from large rehab gym. REPEAT VIOLATION |
|
12
|
1.50
|
Lavatories have mixing faucet or tempered water, soap hand towel and hand drying device |
No |
No
|
No |
Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). Observed no paper towels at hand sink located at restroom near main entrance. |
|
14
|
2
|
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). Observed no EPA registered disinfectant accessible to all shared bathing spas throughout facility. REPEAT VIOLATION |
|
16
|
1
|
Quantitiy and hot water sufficient, backup water supply plan |
No |
No
|
No |
Observed an incomplete backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f). EHS emailed facility a guidance document outlining the items needed for a back up water supply plan. |
|
19
|
1
|
Ice protected, dispensed, equipment clean in good repair |
No |
No
|
No |
Ice shall be handled, transported, stored, and dispensed in such a manner as to be protected against contamination. 15A NCAC 18A .1314 (b).Observed ice chest stored in hallways throughout facility unlocked and unattended. |
|
34
|
1
|
Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately |
No |
No
|
No |
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). Observed personal hygiene items, diapers, and gloves stored with clean linen on clean linen carts throughout facility.
All common linen including sheets, pillow cases, absorbent pads, towels, and wash cloths provided by the facility must be sanitized between users with an EPA registered laundry sanitizer or by other methods described in 15A NCAC 18A .1319 (b). Observed common linens being commingled in facility with no documentation detailing proper sanitization. EHS advised housekeeping management to have their service representative to leave facility with documentation after their visits detailing sanitizer concentration going into the system during each use. |
|
35
|
0.50
|
Patient contact items in good repair, properly stored, cleaned and disinfected |
No |
No
|
No |
Patient contact items that become contaminated during use shall be cleaned and disinfected after each use. 15A NCAC 18A .1319 (c). Observed several patients coming and going out of smal rehab gym and no disinfectant being used to wipe down equipment in small rehab gym. Per conversation with staff member facility had recently ran out of purple top disinfectant wipes. |