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| CDI=Corrected During Inspection | |
R=Repeat Violation | |
VR=Verification Required | |
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| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
3
|
1
|
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 wall damage on 3rd floor hallway, 3rd floor laundry room, 2nd floor hallway, stains on memory care hallway walls, and a damaged baseboard in Room 315. Observed ceiling in Memory Care laundry room with water damage, and bulging tile with cracks. Ensure to repair. 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 shower curtains with pink and black stains in Rooms 366 and 233, and shower chair with pink build up in Room 315.
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed toilet seat loose in Room 366. Observed stains under and/or on toilet seats in MC bathtique, room 260, room 322, and 3rd floor hallway restroom. Ensure to increase cleaning frequency. Repeat violation. |
|
28
|
0.50
|
Adequate storage, area clean, items properly stored |
No |
No
|
No |
All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). Observed patient care items such as briefs stored on the floor of the 3rd floor bathtique storage closet and box of sharp storage on the floor of 3rd floor medication room. Repeat violation.
Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a). Observed patient care items such as towels and briefs stored under sinks of residential rooms. Observed paper towels stored under handsinks of shared bathrooms on the 3rd and 2nd floors.
Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a). Observed shared rooms 221, and MC room 160 with personal care items commingled. |
|
32
|
2
|
Furniture clean and in good repair. Mattresses clean, dry, odor free |
No |
No
|
No |
All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a). Observed mattress torn in Room 315, and mattress stains in Rooms 346 and Room 248. Observed torn chair in Room 366. Observed chair debris in 2nd floor living room and Room 366. Repeat violation. |
|
33
|
2
|
Linen changed when soiled. Soiled linen handled properly |
No |
No
|
No |
Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed stained bed linen in Room 346, 260, 248, and 160. Observed heavily stained pillow in MC Room 160.
Soiled linen shall be placed in a covered container or bag at the point of use and stored and handled so as to contain and minimize aerosolization of and exposure to any waste products. 15A NCAC 18A .1319 (b). Observed soiled linen in MC laundry room uncovered with clean laundry. Ensure to separate. Repeat violation. |
|
35
|
0.50
|
Patient contact items in good repair, properly stored, cleaned and disinfected |
No |
No
|
No |
Soiled patient contact items shall be taken to a designated area for cleaning and shall be stored separately from clean items. 15A NCAC 18A .1319 (c). Based on employee discussion, disinfectant used in Therapy Service is sprayed and left for a contact time of 1 minute before wiping. Disinfectant bottle states to have a minimum contact time of 3 minutes. |
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