CUTHBERTSON VILLAGE

Inspector comments: *NOTE: DON, Renee Brooks, was present during time of inspection. Report emailed to: Elises@ALDERSGATELIVING.ORG Rbrooks@ALDERSGATELIVING.ORG Nelsonm@ALDERSGATELIVING.ORG

Inspector comments: *NOTE: Report emailed to Elises Morren at: Elises@ALDERSGATELIVING.ORG EHS Helen McDonald was present during time of inspection. Report emailed to the following:

Inspector comments: Inspection led by Niejel Wilkins.

Inspector comments: Inspection led by Jeremy Stawinky under the supervision of Jamil Blackmon.

Inspector comments: No Points: #2- Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed lint/debris behind washer/dryer on Bluejay Ln. Laundry detergent spill behind washer on Cardinal wing. Carpet needs vacuuming in office on Oriole Place. #3- Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed damaged walls in soiled laundry rooms. Observed walls need cleaning in resident rooms by toilets and beds. #4- 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). Observed low lighting in laundry room on Cardinal Trail. #33- Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed a couple sheets with holes. Sheets very thin throughout. Leak at backflow preventer at hair wash station in salon.

Inspector comments: No points were deducted for the following: 1. Observed floor in need of caulking in front of the shower in room 30D. **Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b). 8. Observed loose toilet seat in room 7D. **Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). 24. Observed dead insects in the light shield in the soiled room. Observed dead insects on the floor in soiled utility on Cardinal Trail. **Effective measures shall be taken to keep flies, rodents, cockroaches, and other vermin out of the establishment and to prevent their breeding or presence on the premises. 15A NCAC 18A .1317 (a). 32. Observed counter peeling in the kitchenette on Bluejay. Observed chair staining and some worn furniture on the units during the inspection. **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). 33. Observed stained linen/pillow cases in various rooms during the inspection. Ensure that linen is removed once stained. **Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). 42. Observed food out of temperature stored in microwave or countertop on Bluejay and Oriole Wings. Ensure that foods are either kept below 41F or above 135F. Food should be reheated to 165F before eaten if it is cooled for later consumption. **All potentially hazardous food products shall be maintained at 45°F, or below, or 140°F or above except during necessary periods of preparation and serving. 15A NCAC 18A .1323 (a). **Potentially hazardous foods served shall be either consumed or discarded within two hours of being removed from temperature control. 15A NCAC 18A .1323 (a)

Inspector comments: No points deducted for the following: 8.Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed a loose toilet seat in Cardinal trail room 54. Ensure toilet seat is repaired by maintenance. 33.Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed residents personal pillows inside of pillow case with mild staining in Blue Jay room 7D, Oriole Place room 2D, Mallard way room 35D, and Cardinal trail room 61. REHS recommended PIC to let family members of residents know to replace personal pillows that are soiled. Inspection led by Dora sanders

Inspector comments: NO POINTS FOR THE FOLLOWING: #3 Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed walls in room 1092D Soiled Utility in need of repaint. Observed wallpaper in therapy room by the window peeling. Observed wall behind headboard of bed in need of repair and repaint in room 58. #8 Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed stain on toilet seat in room 9D. Observed stain in toilet bowl in room 27D. Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed caulking on the floor of the shower lifting in 30D. #24 Effective measures shall be taken to keep flies, rodents, cockroaches, and other vermin out of the establishment and to prevent their breeding or presence on the premises. 15A NCAC 18A .1317 (a). Observed live water bug and dead insects in shower and bathroom floor in room 26D. Maintenance person was aware during inspection. #32 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). Observed red couch in Livingroom in Oriole place with debris. Observed orange couch in Livingroom in Cardinal Trail with debris. Observed small rip on corner of mattress in room 9D.

Inspector comments: No points were deducted for the following: 12. Provide liquid soap and disposable towels at all hand washing sinks. 15A NCAC 18A .1312 (d). Observed no soap at the handsink in the laundry room on mallard way hall. 32. 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). Observed couch with staining in room 26D.

Inspector comments: No points were taken for the following: 24. Observed dead insects in the light shield in the soiled linen room 1059. **Effective measures shall be taken to keep flies, rodents, cockroaches, and other vermin out of the establishment and to prevent their breeding or presence on the premises. 15A NCAC 18A .1317 (a). 32. Observed stained chair in 32D. Needs to be cleaned. **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). 33. Observed stained linen in 13D and 25D. Needs to be cleaned. **Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). 36. Observed interior of microwave peeling in the satellite kitchen in Oriole Place. **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).

Inspector comments: No points were deducted for the following: 12. Observed laundry room without handwashing soap. Ensure that soap is located at all handwashing sinks. **Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). 32. Observed dresser missing handle in room 42D. Needs to be repaired. **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).

Inspector comments: No points taken: 16. The local health department shall be immediately notified if the primary water supply is interrupted for more than four hours. Each institution shall have a plan to obtain a backup water supply in the event that the water supply is lost for more than four hours. The backup water supply plan shall provide for two liters of water per day per person for drinking. The backup water supply plan shall include a plan for either relocating residents or providing an alternative source of water for essential functions such as food preparation, hand washing, bathing, cleaning, dishwashing, laundry and disposal of bodily waste. The amount of water provided for uses other than drinking may be reduced if the plan includes alternatives for water use for services such as laundry and dishwashing. If an assessment determines that tap water is not to be used for drinking, sources shall be prominently labeled or hooded to restrict use and potable water shall be provided. 15A NCAC 18A .1313(f) Observed backup water supply plan without details of amount of water that will be delivered. 28. Adequate storage, area clean, items properly stored. 15A NCAC 18A .1318(a) Observed depends stored under the sink in the bathroom less than 8 inches off the floor in room 9 and 23. 30. Medication carts clean, sharp containers affixed, food and utensils handled properly. 15A NCAC 18A .1318(c) Observed medication carts on A hall with some debris in front of the narc box. Observed 2 medication carts in A hall that had bleach wipes and disinfectant spray stored with tissues and single service cups that were in plastic bag. 32. Furniture clean and in good repair. Mattresses clean, dry, and odor free. 15A NCAC 18A .1319(a) Observed 1 chair in B hall, 2 chair in C hall and 1 chair in D hall needing cleaning.

Inspector comments: No Points Deducted: 3. Observed one small hole in Housekeeping closet (1119D), needs to be repaired. **Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. 26. Observed four drain flies in room 55. Spoke with maintenance about increasing pest control visits if necessary. **

Inspector comments: #3 - Observed stained and missing ceiling tiles in 1099D laundry room. #4 - Observed lights out in B and C hall soiled utility rooms. Replace lights to ensure rooms are well-lit. #19 - Observed build-up around the shoot and water dispenser of ice machine in Blue jay Lane kitchen. Ensure ice machine is washed, rinsed, and sanitized with a food grade sanitizer at the proper concentration. #28 - Observed toilet paper stored on the floor in the House keeping closet on the Cardinal Trail hall. Observed boxed juice being stored on the floor in the Hummingbird Cafe. Keep patient care items 8 inches above the floor. #33 - Observed one soiled linen cart unlabeled in the soiled linen room on the Cardinal Trail hallway. #35 - Observed build-up of hair in the brushes used in the salon. Ensure brushes are cleaned after each resident. Inspection completed by Savannah Parker with supervision by Tasharra Kenion, REHS

Inspector comments: (NO POINTS DEDUCTED) #3 Observed water stained ceiling tile present in A wing/laundry and in B wing hallway. #5 Observed ceiling vent in A wing laundry collecting heavy debris build up #33 Observed several soiled linen carts not labeled. Label soiled linen carts #36 Observed several microwaves collecting debris build up in need of cleaning including paper line in A wing kitchenette. #30 Observed pill crusher collecting debris in C wing. Keep pill crushed clean. #12 Observed soap not provided in soiled utility closet D wing. Provide soap. #3 Observed hole in wall of A wing house keeping. Keep walls/ceiling clean and good repair.

Inspector comments: (NO POINTS DEDUCTED) Ms. Mary Ellison and Tonia Brewer were present during inspection. #3 Observed water stained ceiling tiles present in laundry room A and B, A hall. **Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. #4 Observed light fixture falling in B hallway. Observed light out in restroom in room 15 of A wing. **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). #5 Observed HVAC vent with dust accumulation in laundry room A, living room B unit, A/C vent room #15. Observed blinds torn in room 15 A wing, with residue build up in same room. **Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). #33 Observed stained/soiled linen present in room 14 A wing. Observed soiled linen trash cans placed in outside closet with labeling on door. Provide labeling on frontside of actual trash can itself. **Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). **Soiled linen shall be placed in a covered container or bag at the point of use and stored and handled so as to contain and **Minimize aerosolization of and exposure to any waste products. 15A NCAC 18A .1319 (b).

Inspector comments: 12: Provide paper towels at B Laundry Room sink.36: Clean the drip pan of the ice dispenser in the Soda Shop. Some areas of the residential kitchens will be inspected 4 times a year with the main kitchen. Domestic refrigeration shall NOT be used to house facility provided bulk food. Grab and go style food, residents' personal food, and condiments are approved to be stored in domestic fridges.

Inspector comments: Mary Ellison, Kerry Alexander, and Tonia Brewer were present during the inspection.#18 - Two ccare givers stated the water pitchers were cleaned at the kitchenette sinks. **Ensure that all drink water pitcher are washed, rinsed, and sanitized properly in the main kitchen.#28 - Observed the exterior storage areas with floors (A, B, and C halls) dirty. **Keep all storage areas clean.#40 - Observed a box of ice cream bars only labeled with the resident's name. **label all food brought by visitors with the resident's name and date.#43 - Observed the refrigerator thermometers were damaged/not working in the Soda Shop and the kitchenette on A hall. **All food storage units must have an accurate thermometer.

Inspector comments: Mercedes Doss and Tonia Brewer were present during the inspection.#15 - Observed no backflow prevention device on the shower head in room 32D. **Provide backflow preventer on all shower wands. **Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).#42 - Observed salad was delivered for lunch at 11am and sitting on the counter top. Lunch begins at 12pm and ends at 2pm. **Recommend labeling delivered food with time of service if the food is not refrigerated. **Potentially hazardous foods served shall be either consumed or discarded within two hours of being removed from temperature control. 15A NCAC 18A .1323 (a)GREAT JOB ! !

Inspector comments: .Mercedes Doss was present during the inspection.General Comments:#2 - Observed the carpet on the A wing with stains. **Keep all flooring clean. See rule .1309 (a).#15 - Observed the new ice machine in the Soda Shop is directly drained. Ensure that the equipment has built-in backflow prevention or provide an air-gap for drainage. Observed some shower wands without backfloe prevention devices. **Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. Seer rule .1313 (d).#36 - One staff member stated that the water pitchers on the med carts were washed at the kitchenette 2 comp sink. Ensure the all water dispensing pitchers cleaned in the kitchen. **All utensils and food contact surfaces of equipment used in the preparation, service, display, or storage of potentially hazardous foods shall be cleaned and sanitized prior to each use. See rule .1320 (c).