| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|
1
|
1
|
Floors easy to clean, no obstacles, drains where needed |
No |
No
|
No |
Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b). Observed flooring in disrepair in nourishment room. Shower needs regrouting in floor/wall junction. Floor tiles missing in conference room |
|
3
|
2
|
Walls and ceilings cleanable, clean, good repair |
No |
No
|
No |
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Repeat-Observed walls damaged and need repair in laundry, rooms where soap or paper towel dispensers a have been replaced or moved. Ceiling in disrepair in family meeting room. |
|
5
|
1
|
Ambient air temperature 65 to 85 F, equipment clean |
No |
No
|
No |
Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). Observed dirty filters in PTAC units throughout. Missing PTAC filters in room 104 |
|
8
|
1
|
Facilities conveniently located, clean and in good repair |
No |
No
|
No |
Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed torn shower bed, both shower beds with build-up in gaps. Undersides of shower chairs and shower curtains soiled.
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed torn toilet seat in room 107. Hoppers need regular cleaning. Observed loose handrail in spa. |
|
12
|
1.50
|
Lavatories have mixing faucet or tempered water, soap hand towel and hand drying device |
No |
No
|
No |
Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). Observed missing soap and/or paper towels throughout facility. Keep all hand sinks properly stocked. |
|
17
|
1
|
Water fountains clean, good repair, properly regulated |
No |
No
|
No |
Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a). Observed dirty water fountains, need cleaning, even if not operable. |
|
19
|
1
|
Ice protected, dispensed, equipment clean in good repair |
No |
No
|
No |
Ice shall be handled, transported, stored, and dispensed in such a manner as to be protected against contamination. 15A NCAC 18A .1314 (b). Observed pink growth on end of ice shield, nourishment room. |
|
28
|
0.50
|
Adequate storage, area clean, items properly stored |
No |
No
|
No |
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). Observed broken bins for storage. Storage rooms, cabinets and drawers in storage rooms, med rooms, etc need cleaning and organizing. |
|
31
|
1
|
Feeding syringes and oral suction catheters handled properly, tube-feeding bags changed per instructions |
No |
No
|
No |
Feeding syringes which are reused shall be labeled with the patient's name and date opened, shall be disassembled and rinsed after each use, and shall be disposed of within 24 hours of first use. 15A NCAC 18A .1318 (d). Room 412-Observed bag not labeled with date and time opened. Observed syringe not rinsed, disassembled before putting back in bag. |
|
32
|
2
|
Furniture clean and in good repair. Mattresses clean, dry, odor free |
No |
No
|
No |
All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a). Repeat- Observed many torn pillows throughout facility. Torn mattresses in rooms 304 and 208. Torn arm on Geri chair. |
|
33
|
1
|
Linen changed when soiled. Soiled linen handled properly |
No |
No
|
No |
Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed soiled/frayed linens on beds in several rooms. |
|
34
|
1
|
Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately |
No |
No
|
No |
Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. 15A NCAC 18A .1319 (b). Observed clean linens stored with non-linens in clean linen rooms.
All common linen including sheets, pillow cases, absorbent pads, towels, and wash cloths provided by the facility must be sanitized between users with an EPA registered laundry sanitizer or by other methods described in 15A NCAC 18A .1319 (b). Observed no records for amount of chlorine going into washing machines. |
|
35
|
0.50
|
Patient contact items in good repair, properly stored, cleaned and disinfected |
No |
No
|
No |
Patient contact items that become contaminated during use shall be cleaned and disinfected after each use or disposed of. 15A NCAC 18A .1319 (c). Observed in spa rooms cabinets had single use and skin contact products stored together. Bar soap, roll on deodorant, razors, nail files, nail clippers, combs and brushes should not be stored all together for using on multiple residents when they are bathed. |