| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
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 scuff marks from lower section of wall in lobby, hallway area and anywhere else needed. Replace cracked/damaged corner wall guard. General Commented |
|
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 (1) emesis basin not labeled identifying emesis basin to patient in the room. General Comment |
|
31
|
1
|
Feeding bags, tubes, syringes and oral suction catheters properly handled |
No |
No
|
No |
.1318 (b) Feeding bags, tubes, syringes, and oral suction catheters shall be stored and used in accordance with the manufacturer's instructions. Observed boxes of items stored on the floor. Store items on shelving. |
|
32
|
0
|
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 chairs in ED worn and damaged. Informed by hospital administrators that furniture has been ordered to replaced damage and worn chairs in ED. Wipe/dust base of computer on wheels (cows) used on different floors. Touch-up old wooden head board with furniture marker used in maternity triage. |
|
33
|
0.50
|
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 (1) soiled linen on isolette (baby warmer). Replace stained linen. Observed clean linen on beds in the public hallway area on different floors. Store a sheet over made beds being stored or placed in the hallway area. |
|
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. THE NEW COLD HOLDING FOR FOOD PRODUCTS IS 41F. Recommend turning down temperatures on refrigeration units to ensure food products are being held at 41F and below. |
|
51
|
0
|
Proper use of restriction, exclusion, and reporting |
No |
No
|
No |
.1324 (c) Institution employees shall comply with the requirements for exclusion from work and restriction due to communicable disease or illness required for food employees as set forth in Parts 2-201.12 and 2-201.13 of the Food Code incorporated by reference at 15A NCAC 18A .2650 as amended by 15A NCAC 18A .2652. Will send administrators the employee health policy. |
|
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. Provide a vomitus's and diarrhea clean up plan and supplies. Will send administrators vomitus and diarrhea clean up plan procedure. |