| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|
1
|
1
|
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 flooring need to be cleaned in memory care unit closet, room 218, 212, 121, kitchen closet upstairs. |
|
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 shower tub needs to be cleaned in room 211, loose toilet seat needs to be repaired in room 206, damaged toilet seat needs to be replaced in room 230, toilet and or hand sink need cleaning in room 218, 212, AL restroom. Observed slow draining at the common area sink in room 218, need repair. |
|
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 men’s restroom main hallway, memory care restroom, AL restroom need hand washing sign posted. Hand washing signs provided at the time of inspection. |
|
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 salon is missing soap for hand washing. Ensure to provide all hand washing supplies at all hand sinks at all time. |
|
16
|
0
|
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 water temperature at the hand sink at some part of the building where it is closed to hot water heater, the temperature was above the required range from 2-3 degrees. The maintenance will adjust the water temperature and keep within the range of 105F to 116F. |
|
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 facilities with incomplete water back up supply plan. EHS emailed administrator the checklist of the plan, and discussed what required at the time of inspection. The administrator will put the plan ready by next inspection. |
|
38
|
0.50
|
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 microwave in memory care dining room need to be cleaned and keep clean. |
|
42
|
0
|
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. Observed boxes of can foods and boxes of single service articles stored on the floor in the kitchen storage upstairs. Maintenance and staff is currently working on getting items up and get rid of some items. Ensure to keep all items off the floor at least 6 inches or above to prevent cross contamination. |
|
45
|
0.50
|
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 memory care unit need the thermometer for temperature indication. |