| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
1
|
0
|
Floors and carpets cleanable, clean, good repair; carpet odor free |
No |
No
|
No |
1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair.
Observed Staining on floor and under rug in the clean linen room and stain on carpet in room18 by heat/ac unit. |
|
2
|
1
|
Walls and ceilings clean, good repair |
No |
No
|
No |
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair.
Observed peeling, water damaged ceilings in multiple areas around facility (men’s restroom, med room, and marketing office). |
|
3
|
0
|
Ceiling attachments cleanable, clean, good repair |
No |
No
|
No |
.1310 (b) Light fixtures, fans, conduits, and heating, ventilation, and air conditioning vents shall be kept clean and in good repair.
Observed exhaust vent dusty in room 11. |
|
5
|
0
|
Ventilation equipment clean, good repair |
No |
No
|
No |
.1311 (b) Ventilation equipment shall be kept clean and in good repair.
Observed filters with heavy build up of dust in rooms 18, 11. |
|
7
|
1
|
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 blueish staining on shower seat in room 40, staining under the toilet seat in the Spa and in room 18, stained shower curtains in the Spa and in room 23, underside of shower seats in disrepair in rooms 36, 23, and staining around the drain in room 18. |
|
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 disposable urinal in room 36 was not identified to the resident. |
|
10
|
0
|
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 hand washing soap in the bathroom of room 18. |
|
15
|
1
|
No cross-connections observed |
No |
No
|
No |
Observed no back flow prevention device on the showers in the Spa or on the faucets behind the hot water tank in the basement. |
|
17
|
0
|
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 back up water plan for facility needed a little more detail in the procedures. (Ie how to flush toilets). |
|
24
|
0
|
Refuse, recyclables, and returnables properly stored |
No |
No
|
No |
.1316 (b) Refuse, recyclables, and returnables shall be stored in containers, rooms, or areas designated for the storage of refuse, recyclables, and returnables.
Observed box of trash stored under shelf in storage room. |
|
27
|
1
|
Medical waste properly handled and disposed of |
No |
No
|
No |
.1316 (e) Medical wastes shall be handled and disposed of as required in North Carolina "Solid Waste Management Rules" 15A NCAC 13B .1200.
Observed sharps container stored in server room connected to med room. |
|
33
|
0
|
Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled |
No |
No
|
No |
.1319 (b) A resident's bed linens shall be changed when no longer clean.
Observed stained sheet in room 36. |
|
34
|
1.50
|
Linens provided by the institution properly cleaned and sanitized |
No |
No
|
No |
.1319 (c) Linens provided by the institution that are not clean shall be cleaned and sanitized in accordance with this paragraph. When hot water in washing machines is used to sanitize linens provided by the institution, the washing machines shall be operated in accordance with the manufacturer's instructions. When chemicals are used to sanitize linens provided by the institution, linens shall be washed in accordance with the following:
(1) using a solution of at least 50 parts per million chlorine; or
(2) using laundry sanitizer that is registered in accordance with 40 C.F.R. 152 and that is used in accordance with the manufacturer's instructions.
Observed sanitizer in the laundry machine was not being calibrated regularly. Calibrate on a regular basis to ensure level of 50ppm is being maintained. Provide maintenance report verifying ppm of chlorine going into machine. |
|
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 refrigerator in Life Enrichment room did not have a thermometer inside the unit. |
|
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.
Observed no written vomitus and diarrheal cleanup plan in facility. |