| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
7
|
2
|
Facilities provided, accessible, clean, good repair |
No |
No
|
No |
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed detailed cleaning needed to hopper in soiled utility room located on rehab unit.
Observed hot water faucet not working at handsink in shared spa room located in memory care unit. Observed detailed cleaning needed to shower tiles and toilet in shared spa room located in memory care unit. Observed black build up at bottom of shower curtains in shared spa room located on 100 hallway. Observed detailed cleaning needed to toilet and shower tiles in shared spa room located on 100 hallway. Observed loose toilet seat in room 1002. Observed brown build up on toilet rim in room 912. REPEAT VIOLATION. |
|
8
|
0
|
Toilet rooms free of storage, handwash signs posted |
No |
No
|
No |
.1312 (b) A sign shall be posted in each toilet room for institution employees, directing them to wash their hands after each visit to the toilet room and before returning to work. Observed handwashing signs missing at employee toilet rooms sporadically throughout building. |
|
9
|
0
|
Bedpans, urinals, bedside commodes and emesis basins properly cleaned and disinfected |
No |
No
|
No |
.1312 (c) When disposable bedpans, emesis basins, and urinals are reused, they shall be labeled so that they are associated with an individual resident. Observed several urinals not labeled according to notated rule (room 903 & room 908). |
|
10
|
1.50
|
Handwashing facilities properly located and equipped |
No |
No
|
No |
.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices. Observed no paper towels at handsink in shared spa room located in memory care unit and 100 hallway. |
|
16
|
1.50
|
Hot water between 105°F and 116°F |
No |
No
|
No |
.1313 (d) Institutions shall provide water heating facilities. Hot and cold running water under pressure shall be provided to carry out all operations. Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities. Observed hot water not within the required range in the following areas: 95F room 903, 95F room 908, 94F room 912, 92F room 1002. |
|
17
|
1
|
Back-up water supply plan available and complete |
No |
No
|
No |
.1313 (e) The institution shall have a written plan to obtain a backup water supply in the event that the institution's primary water supply is interrupted for more than four consecutive hours. The written plan shall identify a backup water supply or alternate source of water that provides two liters of potable water per day per resident and institution employee for drinking and potable water for food preparation, hand washing, bathing, cleaning, dishwashing, laundry, and disposal of bodily waste. This may include a plan for relocating residents to a facility with a water supply that satisfies Paragraph (a) of this Rule. If an institution's primary water supply or backup water supply becomes unsafe for human consumption, then the water sources within the institution, such as sink faucets, shall be labeled or hooded to prevent their use, and the administrator shall provide potable water for use by the institution's residents and employees. Observed no written plan for backup water supply. REPEAT VIOLATION. |
|
38
|
0
|
Food service equipment and utensils clean, good repair |
No |
No
|
No |
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed detailed cleaning needed to microwave in memory care activity room. |
|
42
|
1.50
|
Food and food supplies from approved sources; properly stored and handled |
No |
No
|
No |
.1321 (a) All food and food supplies provided by an institution for consumption by residents shall be from approved sources, stored, and handled as set forth in 15A NCAC 18A .2600. Per conversation with several nursing staff, they are obtaining drinking water for residents to consume meds for nourishment rooms that are equipped with a handwashing sink only. EHS advises facility to obtain drinking water from an approved source only (bottled drinking water, food prep sink in kitchen, water fountains). REPEAT VIOLATION. |
|
45
|
0
|
Hot and cold holding equipment provided; thermometers provided, accurate |
No |
No
|
No |
.1323 (b) Hot and cold holding equipment shall be used to maintain the required temperatures for TCS food. Each refrigeration unit shall be provided with an indicating thermometer that is accurate to ±3 degrees Fahrenheit or ±1.5 degrees Celsius. Observed no thermometer in refrigerator located in memory care unit activity room. |
|
52
|
0
|
Vomitus and diarrheal clean up supplies; written clean up procedures available and complete |
No |
No
|
No |
.1324 (d) The institution shall have gloves, personal protective equipment, disinfectant, individual disposable towels, and a coagulating agent on-site for employees to use and a written procedure for employees to follow when responding to vomitus or fecal matter on institution surfaces. The procedure shall specify the actions that employees shall take to minimize the exposure of employees, residents, guests, food, and additional surfaces to vomitus or fecal matter. Per conversation with administrator, facility has the vomit/diarrhea clean up kits. EHS provided facility with a template procedure to clean up diarrheal/vomitus incidents. |