| Violation Item
| Demerits
| Violation Description
| NA | NO | CDI | R | VR |
|
|---|
| 3 |
2 |
Walls and ceilings cleanable, clean, good repair |
No |
No |
No |
No |
No |
Repeat: Observed: Wall damage throughout facility (resident rooms, resident restrooms, med rooms, soiled utility rooms, dining rooms, nourishment rooms, ice room, etc.) Water damaged ceiling tiles in 3rd floor soiled linen. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. |
| 4 |
2 |
Lighting at least 10 foot candles 30 inches above floor |
No |
No |
No |
No |
No |
Repeat: Observed: No lighting, damaged lighting, and/or inadequate levels of lighting in shower rooms (over toilets), and in some patient rooms (one with tubs).All areas shall have sufficient illumination. Maintain 10 foot candles of light at 30 inches above the floor in all areas other than food service areas. 15A NCAC 18A .1311 (a). |
| 6 |
1.50 |
No evidence of microbial growth |
No |
No |
No |
No |
No |
Observed: Excessive mold growth on block walls in the basement central supply closet.Moisture shall be controlled such that there is no evidence of microbial growth on interior surfaces and objects. 15A NCAC 18A .1311 (d). |
| 8 |
2 |
Facilities conveniently located, clean and in good repair |
No |
No |
No |
No |
No |
Repeat: Observed: All patient room restroom sinks/counter tops damaged. Loose toilet seat in 312. Backsplash caulking damaged/countertops/cabinets damaged in all med rooms. Bathing equipment collecting residue and damaged in all shower rooms. Slow draining sink in 3rd floor nourishment. Loose sink faucet, tile damage at sink, and slow draining sink in 3rd floor shower room. Loose toilet seat in 221. Corroded sink faucet in 2nd floor staff restroom. Hand sink not working in 2nd floor soiled linen room. Corroded sink faucet and loose toilet seat in rehab. No hand washing sink in the ground floor shower/toilet room. Hand washing sinks blocked in soiled linen rooms. Toilet, hand washing, and bathing facilities must be conveniently located and readily accessible to residents and staff. 15A NCAC 18A .1312 (a). Keep all bathing equipment, hand washing sinks, and toilets clean and in good repair. 15A NCAC 18A .1312 (a), (b), and (f). |
| 10 |
1 |
Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected |
No |
No |
No |
No |
No |
Repeat: Observed: Bedpans, bedside toilets, and urinals being used in facility, but facility no longer has in room cleaning capabilities with spray rinse hoses and the only hopper in the basement does not function/accessible for use.Where facilities for cleaning bedpans are not provided in patient rooms, bedpans shall be taken to a soiled utility room and be cleaned and disinfected using an EPA registered hospital disinfectant after each use. 15A NCAC 18A .1312 (c). |
| 14 |
1 |
Disinfectant accessible, properly used |
No |
No |
No |
No |
No |
Repeat: Observed: The key not available for the 3rd floor shower room disinfectant cabinet (improvement observed).A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). |
| 15 |
4 |
Approved water supply, no cross-connections |
No |
No |
No |
No |
No |
Repeat: Observed: No backflow prevention devices on shower wand lines and 3rd floor housekeeping closet. No air gap between the ice machine drain line and sewer line catch basin.Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).(may also need to install vacuum breakers on laundry room water lines) |
| 18 |
1 |
Drinking utensils properly handled |
No |
No |
No |
No |
No |
Repeat: Observed: Drinking water cups only labeled with room numbers.Label all disposable water pitchers with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a). |
| 19 |
2 |
Ice protected, dispensed, equipment clean in good repair |
No |
No |
No |
No |
No |
Repeat: Observed: Ice coolers in nourishment rooms, and the rooms not locked. The interior of the ice machine collecting mold. All ice machines and storage chests which are accessible to the residents and the public shall be automatic ice dispensing machines. 15A NCAC 18A .1313 (b).Ice machines, buckets, other containers, and scoops shall be cleaned on a regular schedule such that they are kept free of scum, rust, mold or other contamination. 15A NCAC 18A .1314 (b). |
| 28 |
0.50 |
Adequate storage, area clean, items properly stored |
No |
No |
No |
No |
No |
Repeat: Observed: Patient care items on the floor in 3rd floor med supply, 1st floor supply room, main housekeeping closet in basement, and shed. Some hair collecting in the salon cabinets. Patient belongings (tooth brush, razor, etc) stored at sink edges in restrooms (observed improvement).Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a).All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). |
| 32 |
1 |
Furniture clean and in good repair. Mattresses clean, dry, odor free |
No |
No |
No |
No |
No |
Repeat: Observed: Several damaged/split pillows throughout. Curtains dirty in several rooms. The bedside/roll table with residue collecting underneath in room 302. Dressers/nightstands/wardrobes damaged throughout.All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, Venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a). |
| 36 |
2 |
Approved utensils and equipment, cleaned and sanitized |
No |
No |
No |
No |
No |
Repeat: Observed: Nourishment room cabinets/shelving damaged throughout. All fridges in need of defrosting and cleaning. A damaged fridge gasket on 2nd floor.Non-food contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. See rule .1320 (c). |