| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
1
|
1
|
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 damaged flooring in spa rooms. |
|
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 scuffed walls where wheelchair have hit it. Doors and door frames with chipped paint. Exterior doors with corrosion. Laundry room ceiling with moisture damage to paint. 200 hall wall damage in custodial closet. |
|
7
|
0
|
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 plumbing leak 200 hall spa. 2 hand sinks leaking from the fixture. |
|
10
|
1.50
|
Handwashing facilities properly located and equipped |
No |
No
|
No |
.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 sink on soiled side of laundry room has been removed. Hand sink needs to be reinstalled. |
|
11
|
2
|
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 staff not using disinfectant correctly. Other staff could not explain how to use the disinfectant properly.Repeat- Disinfectant that is not health care approved being used in PT. |
|
16
|
3
|
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. REPEAT-Observed hot water ranged from 85-122F. Some of the faucets spiked >120F then came back down. Hot water >120F is a scald hazard. Administrator said the mixing valves are being adjusted daily. Mixing valves should not have to be adjusted very frequently. Have system evaluated for mixing valve replacement or back-siphonage from a broken check valve/backflow preventer, or both. |
|
20
|
2
|
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. Repeat-Observed ice in plastic bags inside ice chests. |
|
30
|
1
|
Medication carts clean; sharps containers attached; food, utensils, medication and medication dispensers properly handled |
No |
No
|
No |
.1318 (a) Medication carts shall be kept clean. Observed debris in med cart drawers and pill crushers. |
|
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 debris under cushions in common area. Chair torn in beauty shop. (Lots of improvement) |
|
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 no vomitus clean up plan. (New rule). supply above items including the clean up plan on how to use the above referenced supplies. |