| 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 carpet floor hallway of bath, soiled utility, soiled linen, laundry room.. in a memory care side in need for vacuum and keep clean. Observed soiled floor in bathroom and inside the room H-19, need general cleaning. |
|
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 soiled toilet in room A-02 in AL unit and room H-04 in memory care unit, in need of cleaning and keep clean. |
|
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 no hand washing signs in most the restrooms that staff have access to. CDI- Hand washing signs provided at the 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 facility without manufacturer’s instructions of how to use to the cleaner/disinfectant properly and the amount of contact time on surfaces to effectively clean. When asked the housekeepers, all seems to described how to clean properly. Recommend the facility to obtain manufacturer’s instructions and ensure to train all staff and cleaning staff to properly clean. |
|
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 temperature at 94F- 96F at hand sink in women restroom in memory care unit. CDI- Temperature fixed at 106F at the time of inspection. |
|
17
|
0
|
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 facility has missing information needed in their backup water supplies plan. The administrators are in the meeting at the time of inspection. Facility has a plan at the last inspection. Recommend to locate a full backup water supply plan and have it ready for such an event. EHS will email facility an example of the plan.*** |
|
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 wasp nest, spiders webs hanging on the building outside in the courtyard at memory care unit. Remove all nests and check all around the building. Observed damaged trim under the gutter in courtyard memory care unit. Need repair. |
|
41
|
0.50
|
Food contact surfaces of cooking and baking equipment clean |
No |
No
|
No |
.1320 (d) The food-contact surfaces of cooking and baking equipment, including microwave ovens, shall be kept clean. Observed soiled oven, in need of deep cleaning and maintaining clean in the nourishment room in memory care unit. |
|
44
|
0
|
Time/Temperature Control for Safety (TCS) foods maintained as required |
No |
No
|
No |
.1323 (a) All TCS food shall be maintained at temperatures required by Part 3-501.19 of the Food Code incorporated by reference at 15A NCAC 18A .2650 as amended by 15A NCAC 18A .2653 during storage, preparation, transportation, display, and service of the TCS food. Observed milk temperature in the refrigerator at 44F. Recommend to maintain all TCS food at 41F or below. The ambient temperature of the refrigerator is 42F. The temperature of the refrigerator was adjusted down at the time of inspection. |
|
51
|
0
|
Proper use of restriction, exclusion, and reporting |
No |
No
|
No |
.1324 (c) Institution employees shall comply with the requirements for exclusion from work and restriction due to communicable disease or illness required for food employees as set forth in Parts 2-201.12 and 2-201.13 of the Food Code incorporated by reference at 15A NCAC 18A .2650 as amended by 15A NCAC 18A .2652. NEW RULES. No point deducted. At the time of inspection, Employees Health Policy posters provided and recommend the facility to train staff about EHP to ensure compliance. |
|
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. Observed facility without Vomitus and Diarrhea plan and kits ready for such an event if occurred. V&D clean up procedures poster provided at the time of inspection. Recommend the facility to obtain the kit and have instructions/plan in placed. |