| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
1
|
1
|
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. Observed flooring in disrepair in staff lounge bathroom and bathroom of room 409. Threshold broken room 204. Storage on floor throughout facility, storage needs to be off floor to keep flooring clean. |
|
2
|
1
|
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. Observed scuffed walls throughout. Repair holes in walls where soap, paper towel dispensers or shelving have been removed. Observed wall with microbial growth in room 208 (room is under repair). |
|
3
|
0.50
|
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. Observed ceiling fans in common rooms and especially main laundry room dusty |
|
4
|
0.50
|
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 no lighting in dirty side of main laundry room. |
|
7
|
2
|
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. Repeat- Observed bathrooms need better/thorough cleaning. Buildup under toilet seats and toilet chairs. |
|
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. New Rule- Observed bed pans not labeled. |
|
10
|
3
|
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. Repeat- paper towels missing throughout facility. Replace broken paper towel dispensers. Dispose of bar soap in common areas (residents can use bar soap in their own bathrooms). |
|
11
|
2
|
EPA registered disinfectants used according to manufacturers' instructions; approved testing methods and devices used |
No |
No
|
No |
.1312 (e) EPA registered disinfectants shall be used in accordance with the manufacturer's instructions. When EPA registered disinfectants are mixed and prepared by institution employees, a measuring device, chemical testing device, or the methods and devices prescribed by the chemical manufacturer shall be used to prepare the concentration of chemicals in accordance with the disinfectant's label and the manufacturer's instructions. Observed disinfectant being improperly mixed. Only one dispenser in facility, no extra spray bottles, no spray bottle labeling. Disinfectant bottles located throughout facility where staff mixing. All gallon jugs of disinfectant need to be stored in the custodial closet with the mixing dispenser. Use dispenser to proper water to disinfectant ratio. |
|
12
|
1.50
|
Bathing facilities properly equipped, equipment cleaned and disinfected |
No |
No
|
No |
.1312 (f) Bathing equipment that has contact with a resident's skin and is used by more than one resident shall be kept clean and shall be disinfected between resident uses. Equipment located within a bathing facility that uses a pump to move water shall be kept clean in accordance with the manufacturer's instructions. Observed shower chairs, flooring, toilets in spa rooms need better cleaning of build-up. |
|
15
|
1
|
No cross-connections observed |
No |
No
|
No |
Observed missing backflow preventers on shower wands in several bathrooms. |
|
16
|
1.50
|
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 at 123F in room 302. Hot water 98F bathroom in nurse’s station. |
|
17
|
0.50
|
Back-up water supply plan available and complete |
No |
No
|
No |
.1313 (e) The institution shall have a written plan to obtain a backup water supply in the event that the institution's primary water supply is interrupted for more than four consecutive hours. The written plan shall identify a backup water supply or alternate source of water that provides two liters of potable water per day per resident and institution employee for drinking and potable water for food preparation, hand washing, bathing, cleaning, dishwashing, laundry, and disposal of bodily waste. This may include a plan for relocating residents to a facility with a water supply that satisfies Paragraph (a) of this Rule. If an institution's primary water supply or backup water supply becomes unsafe for human consumption, then the water sources within the institution, such as sink faucets, shall be labeled or hooded to prevent their use, and the administrator shall provide potable water for use by the institution's residents and employees. Repeat-Observed no backup water supply plan. |
|
23
|
0.50
|
Solid waste containers properly constructed, covered where required; good repair |
No |
No
|
No |
.1316 (a) All solid wastes containing food scraps or other putrescible materials shall be kept in leak-proof, non-absorbent containers which shall be kept covered with tight-fitting lids when not in use. Observed doors open on dumpster. |
|
28
|
0.50
|
No pest presence; effective pest control measures |
No |
No
|
No |
.1317 (a) Pests shall not be present in an institution's building or buildings. Observed ants in several areas including resident bathrooms. |
|
29
|
1
|
Pesticides registered and approved for institutional use, properly handled |
No |
No
|
No |
.1317 (b) Only pesticides that are registered in accordance with 40 C.F.R. 152 and G.S. 143-442 shall be used to control pests. Pesticides shall be used, handled, and stored in accordance with the instructions on the manufacturer's label. Observed household bug spray stored unlocked in memory care kitchenette. Do not store hazardous items where accessible to residents. |
|
30
|
0
|
Medication carts clean; sharps containers attached; food, utensils, medication and medication dispensers properly handled |
No |
No
|
No |
.1318 (a) Medication carts shall be kept clean. Observed minor debris in med cart drawers. |
|
32
|
1
|
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. Repeat- Observed debris and garbage under chair/couch cushions throughout. Several common chairs missing casters or have wobbly construction. Make sure all furniture is in good repair. Built in cabinets in resident rooms water damaged, several rooms. |
|
33
|
0.50
|
Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled |
No |
No
|
No |
.1319 (b) Bed linens that are provided by the institution for use by residents shall be free from holes and tears. Observed hole in sheet in room 204.
.1319 (b) A resident's bed linens shall be changed when no longer clean. Observed soiled linens on beds in rooms 49. |
|
36
|
0.50
|
Laundry area and equipment kept clean |
No |
No
|
No |
.1319 (e) Laundry areas and equipment shall be kept clean. Observed main laundry and two resident laundry rooms need cleaning. Dispose of items that are no longer needed/used. |
|
43
|
1
|
Food brought into the institution by employees or visitors of patients or residents properly stored, labeled and dated |
No |
No
|
No |
.1321 (b) Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply as described in rule .1321 (a). Such food shall be labeled with the name of the resident or employee that the food belongs to and the date the food was brought into the institution. Labeling as required by this Rule shall not be required for food items stored in employee-designated or individual residents' refrigerators or rooms. Repeat- Observed staff and resident food in refrigerators without names or dates. |
|
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. New Rule- a vomiting and diarrhea kit with above items and cleanup directions are now required. |