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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 |
|
|---|
|
5
|
2
|
Ambient air temperature 65 to 85 F, equipment clean |
No |
No
|
No |
Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). Repeat: Observed dusty vents in hallway and storage areas. Keep vents clean. Observed PTAC filters dirty as well as microbial growth on the air vents. |
|
8
|
1
|
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 broken toilet riser in room 124. Toilet riser in room 128 needed cleaning. Hoppers need to be maintained clean. Toilet not flushing in spa room.
Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b) Observed leak at sump pump in 1st floor med room.
Facilities in operation prior to March 1, 2003 that do not have handwashing lavatories in all areas required shall have an approved hand hygiene program established. 15A NCAC 18A .1312 (d). Observed no hand sanitizer in beauty shop. Facility to provide. |
|
16
|
2
|
Quantitiy and hot water sufficient, backup water supply plan |
No |
No
|
No |
Repeat-Observed no backup water supply plan. Template emailed.
Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f). |
|
26
|
1
|
Premises clean, no breeding places or rodent harborage |
No |
No
|
No |
The premises shall be kept neat, clean, and free of litter. 15A NCAC 18A .1317 (c). Observed a lot of abandoned furniture near the compactor out of sight of visitors. Remove trash quickly so pests are not encouraged to hang out |
|
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 depends, dermal wound care, and ear thermometer covers stored below hand sink plumbing. Observed liquid meal replacement stored on floor, med room 1st floor. Observed soiled pillow and other items stored on floor of closet, room 105. |
|
32
|
1
|
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 trash/debris under cushions of common furniture. |
|
33
|
1
|
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 threadbare top sheet on bed in room 105. Soiled linens in rooms 113, 124 and 128. |
|
34
|
1
|
Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately |
No |
No
|
No |
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). Through discussion the bibs are washed in the onsite laundry room, they are not using an EPA laundry sanitizer.
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 shower curtains not wrapped around entire shelf in clean linens rooms. |
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