| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
3
|
0
|
Ceiling attachments cleanable, clean, good repair |
No |
No
|
No |
.1310 (b) Light fixtures, fans, conduits, and heating, ventilation, and air conditioning vents shall be kept clean and in good repair. Observed room 604 AC air filter need to be cleaned and keep clean. Observed water stain on ceiling in back service hall, the facility has been working on fixing the issue. |
|
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 hand washing sink was blocked (No access to hand washing) by big bins/medical supplies in clean and soil utility room. Refrigerator was blocking the hand sink in the med room on copper ridge hall/hunt on brook hall. Ensure to provide access to all hand washing sinks at all time. Observed loose toilet seat in room 712, 504, men’s room in the front service hall, in spa room on Hunton brook hall, Need repair and keep in good repair. Observed hard water stain on toilet in spa room on hunton brook hall, need cleaning. Observed broken/damaged/missing shower faucet knobs/shower head/handles, need repair or replace in spa room on hunton brook hall, spa room on 100 hall. |
|
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 roller bedside table stored in spa room hunton brook hall. Observed a pillow on a shower bed in spa room 300 hall. |
|
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 soap and/or paper towel dispensers is not working causing no soap/paper towel available for hand washing at hand sinks in clean linen rooms, soil rooms on hunton brook hall, copper ridge hall. Ensure to provide hand washing supplies and made available at all hand sinks at all time. |
|
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 with an incomplete water back up supplied plan. EHS sent PIC an example plan and discussed details needed at the time of inspection. PIC is going to make a detail plan and put it together for next inspection. No point escalating this time. |
|
18
|
0
|
Drinking fountains clean, good repair |
No |
No
|
No |
.1314 (a) Drinking fountains shall be kept clean and in good repair. Observed on of the water fountain on hunton brook hall with high water pressure. Adjustment needed. |
|
23
|
0
|
Solid waste containers properly constructed, covered where required; good repair |
No |
No
|
No |
.1316 (a) All solid wastes containing food scraps or other putrescible materials shall be kept in leak-proof, non-absorbent containers which shall be kept covered with tight-fitting lids when not in use. Observed one of the dumpster is missing a drain plug, need a replacement. |
|
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 food debris/dust underneath the sofa in a living room at front service hall. Need cleaning and keep clean. Observed stained, damaged/frayed corners of mattresses in room 504, 712, 601, 606. Observed damaged pillows in room 108. All item need to be cleaned and keep in good repair. |
|
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 laundry machine service records for sanitizing linens. PIC trying to reach out to a company and couldn’t be reached to obtain a record during the inspection. The facility will have all the records needed for next inspection. |
|
38
|
0
|
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 rusted microwave in a nourishment room copper ridge hall, need repair or replace. Keep in good condition. |
|
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. Observed pimento cheese sandwiches in the refrigerator in nourishment room on copper ridge hall, date marking 6/6/23. CDI- PIC volunteers to discard items. Kitchen staff stated that they were made yesterday and put on the wrong date. Ensure to put a correct date and discard item when expired. |
|
52
|
0
|
Vomitus and diarrheal clean up supplies; written clean up procedures available and complete |
No |
No
|
No |
REPEAT
.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 Vomiting and Diarrhea plan and kit available at the time of inspection. V&D clean up poster provided at the time of inspection. The facility need to obtain a V&D clean up kit and made available in such an event. No point escalating at this time. |