| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
3
|
1
|
Walls and ceilings cleanable, clean, good repair |
No |
No
|
No |
Observed some wall damage throughout facility.
**Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
Repeat
Observed food debris, as well as other buildup on the floors in rooms 301, and 202. Floors in need of cleaning.
**Keep all flooring clean. 15A NCAC 18A .1309 (a). |
|
5
|
1
|
Ambient air temperature 65 to 85 F, equipment clean |
No |
No
|
No |
Observed vent filters with heavy accumulation in rooms 214, 102 and 408. Filters in need of cleaning. Observed missing filters in ventilation equipment in room 202.
**Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).
Repeat |
|
8
|
1
|
Facilities conveniently located, clean and in good repair |
No |
No
|
No |
Observed bathing equipment in need of cleaning. Observed pink, white and orange build up on shower heads, shower seats, and on shower. Ensure bathing equipment is kept clean.
**Keep all bathing equipment clean and in good repair.15A NCAC 18A .1312 (a) and (f).
Observed rusted toilet chair in room 305, observed toilet not working in room 301, as well as toilet chair in need of replacing.
**Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). |
|
12
|
3
|
Lavatories have mixing faucet or tempered water, soap hand towel and hand drying device |
No |
No
|
No |
Observed no soap and paper towels in memory care common bathroom, nor at the kitchenett, paper towels and soap not provided in shower room (memory care). Observed no soap or paper towels in laundry room, as well as in 100 hall way bathroom.
**Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d).Repeat
Observed no water for handwashing in laundry room. Observed sink not plummed. Ensure sink is fixed within 30 day.
**All lavatories shall be supplied with hot and cold running water through a mixing faucet, or with tempered warm water. 15A NCAC 18A .1312 (d). |
|
14
|
2
|
Disinfectant accessible, properly used |
No |
No
|
No |
Observed cleaning detergent as well as EPA registered hospital disinfectant not accessable to bathing areas. Observed housekeeping employee ussing a household cleaner in bathrooms, housekeeper stated she only uses clorox spray cleaner.
**A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).
Repeat |
|
28
|
1
|
Adequate storage, area clean, items properly stored |
No |
No
|
No |
Observed patient care items, such as disposable underwear being stored on the floor throughout inspection. Ensure that disposable items are being stored off of the floor.
**All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
Repeat |
|
33
|
2
|
Linen changed when soiled. Soiled linen handled properly |
No |
No
|
No |
Observed bed linen in need of cleaning in 102, 301, 214, 408, and 405.
**Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).
Repeat |
|
40
|
1
|
Food brought by employees or visitors handled properly |
No |
No
|
No |
Observed resident's food in common refrigerators without proper labeling of names and dates. Ensure food brought in facility is being labeled with residents name and date.
**Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food
supply and shall be labeled with the name of the person to receive the food and the date the food was brought into the facility. 15A NCAC 18A .1321 (b). Repeat |
|
43
|
0.50
|
Food storage units with thermometers, maintain temperatures |
No |
No
|
No |
Observed no thermometer in refrigerators throughout. Ensure thermometers are provided in each refrigeration unit.
**All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b).
Repeat |