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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 |
|
|---|
|
2
|
1
|
Floors clean, carpet clean, dry, odor free |
No |
No
|
No |
Observed debris on some hallway carpets, the floor grout needed cleaning near the toilet in room 219, and some floors on service halls needed cleaning.
**Keep all flooring clean. 15A NCAC 18A .1309 (a). |
|
8
|
2
|
Facilities conveniently located, clean and in good repair |
No |
No
|
No |
Repeat Non-Compliance - Observed 2 dirty hoppers, the toilet was soiled in room 219
Observed the shower curtain was not clean and the shower chair was soiled in room 219, and the shower tile and grout with pink residue in room 110.
Observed several hand washing sinks were not clean (nourishment rooms, clean and soiled utility, service kitchens). **Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). **Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). **Keep all hand washing facilities clean and in good repair. 15A NCAC 18A .1312 (b) |
|
10
|
0.50
|
Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected |
No |
No
|
No |
Repeat Non-compliance - Observed a bedpan with worn off label in room 412, and staff stated bedpans were cleaned in the resident's rooms which are not equipped for cleaning bedpans.
**Where facilities for cleaning bedpans are not provided in patient rooms, bedpans shall be taken to a soiled utility room and be cleaned and disinfected using an EPA registered hospital disinfectant after each use. 15A NCAC 18A .1312 (c). |
|
28
|
0.50
|
Adequate storage, area clean, items properly stored |
No |
No
|
No |
Observed a staff member's belongs were stored with the clean supply items, unopened fill spouts were stored in the soiled utility room, and open bag of disposable briefs were stored on the floor in the lift storage room. **Keep all staff's personal belongings stored separate from facility supply items.
**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).
**All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). |
|
33
|
2
|
Linen changed when soiled. Soiled linen handled properly |
No |
No
|
No |
Repeat Non-Compliance - Observed large soiled linen containers in the soiled utility rooms were not labeled as soiled linen, one pillow case was not clean in room 504, the bed spread was not clean in 110. **Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).
**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).
NOTE: Large soiled linen bins must be covered during transport to laundry room. |
|
43
|
0.50
|
Food storage units with thermometers, maintain temperatures |
No |
No
|
No |
Observed no thermometer in the 500 hall nourishment room.
Observed three facility supplied refrigerators with internal temperature at 50F. The sandwich wrap and cut melon stored in the refrigerator in room 301 were discarded.
**All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b).
**All refrigerators shall maintain a temperature of 45°F or below. 15A NCAC 18A .1323 (b). |
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