| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
1
|
0
|
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 the C wing auxiliary kitchen that was sticky to the touch from previously spilled liquids. Observed dropped food on bathroom floor in room B5. |
|
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 dried blood on storage doors in B wing. Observed scuffed and dirty walls in storage room in C wing and bathroom walls of C5 and C11. Observed several areas of smudged hand prints on doors, near switch plates, etc. |
|
7
|
1
|
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. Observed buildup on toilet in Spa A. Observed loose toilet seats B7, Spa C, common women’s room in wing D. Bathing facilities in spas B were visibly dirty. Spa A was leaking. |
|
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 disposable towels or alternative hand-drying device in A3, C5, C11, B5, or B wing nurse laundry room.
.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 med storage with opened containers of pills. Room does not have a hand washing sink therefore all meds need to be handled at med cart. |
|
11
|
1
|
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 unlabeled spray bottles of chemicals. Label all chemicals when stored outside of original container. |
|
12
|
0
|
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 no disinfectant in Spas open to use by more than one resident. |
|
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 water temperatures below 105F in rooms A3, A12, A wing nurse station, Spa B, C5, C11, D4, D7, D wing common women’s restroom, and beauty parlor. |
|
26
|
0
|
Premises properly maintained |
No |
No
|
No |
.1316 (d) An institution's exterior premises, including parking lots, lawns, and walkways, and interior premises within the institution's building or buildings, shall be kept free of garbage, solid waste, yard trash, and pest harborages. Observed dumpster storage open to pests with extensive debris surrounding outside of dumpster. Close doors and clean surrounding area to prevent harborage of pests. |
|
34
|
1.50
|
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 chlorine bleach being used to sanitize institution’s linens, but no means to test ppm. Testing log was observed on wall, but had not been filled out since 2020. |