|
8
|
2
|
Facilities conveniently located, clean and in good repair |
No |
No
|
No |
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed toilets with build up of soil in several patient bathrooms. EHS encourages facility to complete detailed cleaning to toilets throughout to include toilet basin and outside of toilets. Observed loose toilet seat in room 113.
Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed black build up on shower tiles in shard spa room on memory care unit and 100 hallway shared spa room.
Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b). Observed loose handsink faucet in memory care shared spa room.
REPEAT VIOLATION. |
|
9
|
0.50
|
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 in shared spa room on 100 hallway to include a stereo and chairs/furniture.
REPEAT VIOLATION. |
|
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 community spa located in memory unit and 100 hallway missing EPA registered disinfectant.
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.
REPEAT VIOLATION. |
|
19
|
2
|
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 hallway unattended and not locked on several hallways.
Ice machines, buckets, other containers, and scoops shall be cleaned on a regular schedule such that they are kept free of scum, rust, mold or other contamination. 15A NCAC 18A .1314 (b). Observed pink build up inside ice machine located on 300 hallway nourishment room. REPEAT VIOLATION. |
|
34
|
2
|
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 hygienic items stored on clean linen carts throughout facility.
REPEAT VIOLATION.
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 no documentation detailing how much bleach is pumped into system when commingling of linens is occurring. |
|
39
|
2
|
Food supply complies with 15A NCAC 18A .2600 |
No |
No
|
No |
All food and food supplies provided by an institution shall be from sources that comply with 15A NCAC 18A. 2600. Per nurse on memory care unit water is filled from handsink in medication room to give to residents to take their medication. EHS advises facility to obtain drinking water from an approved source (food prep sink in kitchen, water fountains, bottled drinking water). |