| 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 rusting and detailed cleaning needed to floor tiles in storage/supply room on west wing near nourishment room. |
|
2
|
0
|
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 stained ceiling tile on East wing. |
|
5
|
0
|
Ventilation equipment clean, good repair |
No |
No
|
No |
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed dust accumulation on removable vents in rooms 141 and 161 |
|
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 cleaning needed to green bath mat on west wing shard spa room. Observed loose toilet seat in room 141. Observed rear of toilet chair rusting in room 155. |
|
8
|
0.50
|
Toilet rooms free of storage, handwash signs posted |
No |
No
|
No |
.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed wheels chairs and boots stored in shower stall in shared spa room on west wing.
.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 hand washing sign missing at handsink in shared spa room on west wing. |
|
10
|
0
|
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 paper towels missing from handsink in shared spa room on west wing. PIC supplied paper towels to handsink during time of inspection. |
|
11
|
0
|
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 no testing kit to measure the concentration of “Brutab6s disinfectant/sanitizer tablets” that are prepared with water by institution employees. |
|
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 below required range in the following rooms: room 134; 101F, room 145; 97F, room 155; 98F, room 161; 98F. |
|
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. Observed incomplete back up water supply plan. |
|
28
|
0
|
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 an alive insect on green bathing mat in shared spa room on west wing. |
|
32
|
0.50
|
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. Observed blue/white pillows torn in the following rooms: 108, 134, and 141. Observed cabinet in need of repair in nourishment room on west wing. |
|
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 staining on bed linen in the following rooms: 120, 134, and 141. |
|
38
|
0.50
|
Food service equipment and utensils clean, good repair |
No |
No
|
No |
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed detailed cleaning needed to refrigerator stored in nourishment room on east wing. |
|
42
|
0
|
Food and food supplies from approved sources; properly stored and handled |
No |
No
|
No |
.1321 (a) All food and food supplies provided by an institution for consumption by residents shall be from approved sources, stored, and handled as set forth in 15A NCAC 18A .2600. Per conversation with nursing staff water for residents to drink for taking their medication is obtained for the nourishment room handsinks. EHS advises nurses to obtain water from the kitchen approved food prep sinks, water fountains, or bottled water. |