| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
1
|
1
|
Floors and carpets cleanable, clean, good repair; carpet odor free |
No |
No
|
No |
REPEAT
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 damaged/missing floor tiles in east shower 2, east pantry under the refrigerator, in boiler room. Observed soiled shower rooms floor throughout the facility need detail cleaning and keep clean. Point remain the same. |
|
2
|
2
|
Walls and ceilings clean, good repair |
No |
No
|
No |
REPEAT
.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 wall plugs panel came off the wall in 118, damaged wall/missing based boards in 104, 109, 110, 212, laundry room. Filling up holes in wall and touching up paint on wall throughout the facility needed. Keep all wall in good repair. Observed Laundry room ceiling covered with dusts, needs cleaning. |
|
3
|
0.50
|
Ceiling attachments cleanable, clean, good repair |
No |
No
|
No |
REPEAT
.1310 (b) Light fixtures, fans, conduits, and heating, ventilation, and air conditioning vents shall be kept clean and in good repair. - Observed flickering light on west wing hallway. No light in 109, the of restroom 104, and the staff restroom east wing. Need repair or replace. |
|
5
|
1
|
Ventilation equipment clean, good repair |
No |
No
|
No |
REPEAT
.1311 (b) Ventilation equipment shall be kept clean and in good repair.- Observed AC filters throughout the building covered with lots of dusts, need detail cleaning. Observed broken/missing AC filters in 221, 225, 109, 121, need repair or replacement. |
|
7
|
2
|
Facilities provided, accessible, clean, good repair |
No |
No
|
No |
REPEAT
.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.- Observed soiled toilet in room 121, 101, the gym restroom need cleaning. Observed rusted toilet chair in west bath 1, 101, gym restroom. Observed loose/damaged toilet seat in 225, front entrance hallway restroom, restroom in the gym. Need repair or replace as see fit. |
|
8
|
0
|
Toilet rooms free of storage, handwash signs posted |
No |
No
|
No |
.1312 (b) A sign shall be posted in each toilet room for institution employees, directing them to wash their hands after each visit to the toilet room and before returning to work. - Observed restroom in the gym need hand washing sign. Hand wash signs emailed at the time of inspection |
|
10
|
1.50
|
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. Observed no soap in west bath 2. Need refill.
.1312 (d) Handwashing facilities shall be located in an institution in accordance with 10A NCAC 13B .5411, 10A NCAC 13D .3201, 10A NCAC 13F .0305, .1304, and 10A NCAC 13K .1109, .1204, as applicable. Institutions that do not have a handwashing facility located in all areas required by this Paragraph shall not be required to install handwashing facilities if the institution has an approved hand hygiene program.- Observed hand washing sinkis not available for hand washing, it was blocked by food/tray/ supplies in west pantry, plastic bag/items inside the hand sink in west soiled room and Bio hazard room east wing, the bath bed blocked in front of the hand sink in west bath 1. Ensure not to block and provide access for hand washing at all hand sinks at all time. |
|
16
|
0
|
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 throughout the facility water temperature some part is within range and some part is up to 120F (room 118, 101, 216, 230). According to maintenance, the facility had an incident with their water heater. This Monday coming up 10/30/23, the company will be out to adjust and ensure the water temperature is within the required range. |
|
17
|
0.50
|
Back-up water supply plan available and complete |
No |
No
|
No |
REPEAT
.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. - Observed the facility without complete water backup supplies plan. EHS email the checklist for water backup supply plan to maintenance and administrator at the time of inspection. Obtain the complete water backup supply plan for the facility. |
|
18
|
0.50
|
Drinking fountains clean, good repair |
No |
No
|
No |
REPEAT
.1314 (a) Drinking fountains shall be kept clean and in good repair. - Observed rusted and soiled water fountain in the therapy gym and soiled water fountain on west wing, need cleaning and keep clean. |
|
20
|
1
|
Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair |
No |
No
|
No |
.1314 (c) Ice shall be protected against physical, chemical, and biological contamination and shall be kept clean. - Observed ice cooler sat outside the pantry room east wing. When asked, staff moved the ice cooler in the lock pantry room at the time of inspection. |
|
32
|
1
|
Furnishings clean and in good repair; mattresses dry, clean, good repair |
No |
No
|
No |
REPEAT
.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 damaged wheelchair armrest in hall, and therapy gym. Tears blue table/bed in therapy gym. Observed damaged pillows in room 230 and damaged mattress in room 101. Need repair or replace. |
|
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 soiled blanket/bed covered in room 230. Need cleaning. Observed soiled sheet in room 104, 101, need cleaning. |
|
34
|
0
|
Linens provided by the institution properly cleaned and sanitized |
No |
No
|
No |
.1319 (c) Linens provided by the institution that are not clean shall be cleaned and sanitized in accordance with this paragraph. When hot water in washing machines is used to sanitize linens provided by the institution, the washing machines shall be operated in accordance with the manufacturer's instructions. When chemicals are used to sanitize linens provided by the institution, linens shall be washed in accordance with the following:
(1) using a solution of at least 50 parts per million chlorine; or
(2) using laundry sanitizer that is registered in accordance with 40 C.F.R. 152 and that is used in accordance with the manufacturer's instructions.
- Observed the facility without the record of chemicals that use to sanitize the linens that facility provides. Obtain and keep file of the laundry records. |
|
45
|
0
|
Hot and cold holding equipment provided; thermometers provided, accurate |
No |
No
|
No |
.1323 (b) Hot and cold holding equipment shall be used to maintain the required temperatures for TCS food. Each refrigeration unit shall be provided with an indicating thermometer that is accurate to ±3 degrees Fahrenheit or ±1.5 degrees Celsius. - Observed internal thermometer needed inside the refrigerator in east pantry room. |
|
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. - Observe the facility without diarrhea and vomiting written procedure/supplies. EHS emailed the poster at the time of inspection. |