| 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. Continue to clean floor throughout in common areas, storage rooms, etc. Replace broken base tile cove molding. Clean floor under shelving in clean supply 7F. Clean floor behind washer in 7D |
|
2
|
0
|
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. Continue to wipe/clean walls throughout where needed; if needed. Touch up paint door framing and corner edges of walls throughout where needed. Observed walls and doors scuffed throughout in areas, Observed doors chipped throughout in areas (7D, 7E and 7F). Clean scuff marks from walls and doors. Replace or refurbish chipped doors. Clean stains on wall in soiled room(OR-B). |
|
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. Clean ceiling vents in R730 and R719. |
|
4
|
0
|
Lighting at least 10 foot candles, 30 inches above floor |
No |
No
|
No |
.1311 (a) The areas interior to an institution's building or buildings shall be equipped with at least 10 foot candles of light at 30 inches above the floor. Observed light fixture not operating in fixture above shower in patient bathroom; replace light bulb or repair light fixture. |
|
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. Repair broken shower wand holder in (1) bathroom/shower. Observed (2) hand washing sinks not operating at time of inspections. Batteries replaced at time of inspection and hand washing sinks were operating. Observed microbial growth in grout in shower in rooms 707 and 719. Thoroughly clean grout in shower and recommend resealing.Thoroughly clean and disinfect showers daily. Observed old soap and band aid in ledge within shower. Observed soiled shower curtain in room 793 and 730. Thoroughly clean hand washing sink in 7E; observed build up around backside of faucet handles. |
|
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 no handwashing signs posted employee restrooms throughout. Handwashing signs provided at 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 soap not available at hand washing sink in nourishment area in 7D and at two room in area. (Behavior health) |
|
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 hot water under required range in the following areas at handwashing sinks: 5C nourishment room, 6C soiled utility room and room 6106. Entire floor of Endoscopy hot water 138F (work order already placed before walk-through). Observed water temperature 100F-104F in ACU and PEDS. Observed water temperature at hand washing sink in nourishment area of 7E 59F. Observed water temperature 75F at bathroom before locked ward. No points deducted. Maintenance was in the process of addressing hot water issue at time of inspection in areas of concerns. |
|
32
|
0.50
|
Furnishings clean and in good repair; mattresses dry, clean, good repair |
No |
No
|
No |
.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair. Observed (1) damaged mattress in clean supply room. Discard and replace damaged mattress. Observed (1) bench in lobby area near elevator with damaged leg. Repair or replace damaged bench. Wipe/dust top of high fixtures; light dusting needed. Clean base of computer on wheels(cows).Observed damaged wheel chair near triage room on L &D. Observed damaged chair in 772. Observed debris in base of drawer in a clean vacant room 7806. Observed seating of wheel chair damaged. Recommend replacing damaged seating on wheel chair. |
|
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.
.1319 (b) Bed linens that are provided by the institution for use by residents shall be free from holes and tears. Replace torn pillows in 707, 715, 735. Observed blood on blanket in room 735. |
|
36
|
0
|
Laundry area and equipment kept clean |
No |
No
|
No |
Observed interior of clothes washer machine rusted in 7D. Refurbish or replace lid. |
|
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 soiled refrigeration unit in 7E. Observed cabinets, and base of drawers with spillage in 7F nourishment. |
|
44
|
0
|
Time/Temperature Control for Safety (TCS) foods maintained as required |
No |
No
|
No |
.1323 (a) All TCS food shall be maintained at temperatures required by Part 3-501.19 of the Food Code incorporated by reference at 15A NCAC 18A .2650 as amended by 15A NCAC 18A .2653 during storage, preparation, transportation, display, and service of the TCS food. Observed milk in nourishment refrigeration unit in 6F unit reading 44F-46F. Temperature in refrigeration unit lowered and milk spaced and placed in back of unit. |