BROOKDALE WEDDINGTON PARK

General Comment: .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 minor ceiling crack in room 28. Needs repair.

.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 shower liner and floor with build up in 46. Observed shower floor with some minor debris in 50. Observed build up/rusting under shower seat in 38 and 23. Observed shower floor strips peeling and hose with some build up/rusting in 28. Observed shower walls peeling in 11. 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 bottom of shower chairs cracked and/or in need of cleaning in 51, 33, 21 and 2. Observed shower head in need of cleaning in 8. Needs cleaning/repair.

.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 crumbs/debris under chair cushions in sitting area. Needs cleaning.

.1314 (a) Drinking fountains shall be kept clean and in good repair. Observed black build up on water fountain nozzle by rehab room. Water fountain is turned off and not in use, EHS still advise facility to clean unit. -General comment.

.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 minor scuff markings to walling throughout building.

.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 cabinet in bathroom of room 29 peeling. Observed bottom of bathroom door with scuff markings of room 29.

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 minor carpet staining sporadically in rooms throughout facility.

.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 minor ceiling stains near entrance to hallway apartments 40-51 around ceiling light. EHS advises facility to ensure no active leak is occurring and to have stained ceiling tiles replaced.

.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 staining under toilet chair lid in room 8.

.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 minor debris behind dumpster area.

.1321 (b) Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply as described in rule .1321 (a). Such food shall be labeled with the name of the resident or employee that the food belongs to and the date the food was brought into the institution. Labeling as required by this Rule shall not be required for food items stored in employee-designated or individual residents' refrigerators or rooms. Observed 2 containers of food stored in refrigerator in Life Enrichment Area with no labeling. EHS advises facility to follow notated rule.

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 Staining on floor and under rug in the clean linen room and stain on carpet in room18 by heat/ac unit.

.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 peeling, water damaged ceilings in multiple areas around facility (men’s restroom, med room, and marketing office).

.1310 (b) Light fixtures, fans, conduits, and heating, ventilation, and air conditioning vents shall be kept clean and in good repair. Observed exhaust vent dusty in room 11.

.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed filters with heavy build up of dust in rooms 18, 11.

.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 blueish staining on shower seat in room 40, staining under the toilet seat in the Spa and in room 18, stained shower curtains in the Spa and in room 23, underside of shower seats in disrepair in rooms 36, 23, and staining around the drain in room 18.

.1312 (c) When disposable bedpans, emesis basins, and urinals are reused, they shall be labeled so that they are associated with an individual resident. Observed disposable urinal in room 36 was not identified to the resident.

.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices. Observed no hand washing soap in the bathroom of room 18.

Observed no back flow prevention device on the showers in the Spa or on the faucets behind the hot water tank in the basement.

.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 back up water plan for facility needed a little more detail in the procedures. (Ie how to flush toilets).

.1316 (b) Refuse, recyclables, and returnables shall be stored in containers, rooms, or areas designated for the storage of refuse, recyclables, and returnables. Observed box of trash stored under shelf in storage room.

.1316 (e) Medical wastes shall be handled and disposed of as required in North Carolina "Solid Waste Management Rules" 15A NCAC 13B .1200. Observed sharps container stored in server room connected to med room.

.1319 (b) A resident's bed linens shall be changed when no longer clean. Observed stained sheet in room 36.

.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 sanitizer in the laundry machine was not being calibrated regularly. Calibrate on a regular basis to ensure level of 50ppm is being maintained. Provide maintenance report verifying ppm of chlorine going into machine.

.1323 (b) Hot and cold holding equipment shall be used to maintain the required temperatures for TCS food. Each refrigeration unit shall be provided with an indicating thermometer that is accurate to ±3 degrees Fahrenheit or ±1.5 degrees Celsius. Observed refrigerator in Life Enrichment room did not have a thermometer inside the unit.

.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 written vomitus and diarrheal cleanup plan in facility.

Observed hair in rollers in the beauty salon. Ensure that rollers are cleaned after each use. **Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c). NOTE: Facility has recently went through renovations with much of the furnishings in common areas replaced.

Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). Observed build up on ac vents in rooms 32, 12, and 9. Need cleaning.

Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed soiled toilet seat and cracked shower seat in room 7 and damaged toilet seat in room 37. Need cleaning/repair.

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 stained seat cushion and leftover candy trash under seat cushions at common areas. Need cleaning.

All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b). Observed no thermometer in room 44 and room 7.

Observed ceiling peeling in C hall foyer. Observed paint is peeling on bottom on wall in various areas (public restrooms, housekeeping closet, etc). Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.

Observed pillowcases stained in room 1A. Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).

Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). ***REPEAT*** Observed stains under lid on toilet seats in Spa Rm and on toilet seat in Rm #7 & 2. Observed urine stains around the base of the toilet in Rm #25. Spoke to PIC to have staff to clean toilets.

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). Observed resident's refrigerator stored outside beside entry/exit door. Remove.

Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c). Observed physical therapy table in need of cleaning. Observed resident's seat cushion on the floor in storage closet. PIC removed cushion off the floor.

All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b). Observed no thermometer in refrigerator in Rm #33 & 44.

Observed stains under lid on toilet seats in Rm #42, and Rm #9. Spoke staff about having toilets cleaned. **Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).

REPEAT: -Observed pink buildup under the shower seat in the shower room. -Observed buildup in the toilet seat, handle, and bowl in room 47. Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).

Observed water temps at 130F. Regulate to get the range stated in the rule below. Maintain the hot water at all resident accessible handwashing sinks and bathing facilities within the temperature range of 100°F to 116°F. 15A NCAC 18A .1312 (e).

-Observed heavy buildup in the bottom of the medicine cart. Clean. Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c). -Observed pill cups stored unprotected on the medicine cart. Inverted. Unused medication cups shall be kept covered or inverted. 15A NCAC 18A .1318 (c).

Observed black residue on HVAC vents in spa room, room 24, room 9, and in hallway near room 9. Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).

Observed shower chairs in spa room with residue on under carriage or legs. Observed stains/residue on toilet chair and potty chair in room 24. Observed pink residue on shower head in room 24 and room 9. Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).

Observed hair in rollers in salon. Clean items between each use. Observed blue table pad starting to rip/tear around edge in Rehab. Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).

Observed stained toilets in room 2, spa and 19. Toilet chair in room 2 was replaced. Spoke with housekeeping staff about having toilets cleaned. **Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). I

Observed disposable underwear stored on the floor in the bathroom in room 2. Disposable items were removed. **All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).

Observed stains on toilet and toilet chairs rooms 42, 24, and 5. Observed stain on toilet in mens room across from salon. Observed stained toilet seat and tub in 24. Observed stains under lid on shower toilet chair in spa. Showerhead has pink residue in room 5. Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).

Observed patient care items such as diapers stored on floor in storage closet on D wing. All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).

Observed hair in brushes in salon. Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).

Observed toilet and toilet chair soiled in rooms 44 and 26. Observed shower chair stained in spa room. Observed stained shower head sprayers or shower sprayer line (rust) in rooms 44 and 24. Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).

Observed hot water 117-119F in public restroom, therapy room, room 26, 24, and suite 5 restrooms. Maintain the hot water at all resident accessible handwashing sinks and bathing facilities within the temperature range of 100°F to 116°F. 15A NCAC 18A .1312 (e).

Observed diapers, gloves, and other patient care items stored on floor in storage rooms. All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).

Observed wall damage throughout in room 9. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.

Observed shower heads needing to be cleaned in room 11, 17, 31, 45 and spa. Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).

Observed black residue in refrigerator in room 9. All kitchenware and food contact surfaces of equipment, exclusive or cooking surfaces of equipment, used in preparation or serving of food or drink, and all food storage utensils, shall be cleaned after each use. 15A NCAC 18A .1320 (c).

Observed vanity damage in rooms 5 and 46. Loose toilet seat in room 46. Loose non-slip treads in shower, room 41. Tear in shower seat, spa. **Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b) **Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).

Observed water fountain with pressure too high and splattering onto floor. **Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a).

Observed no thermometers in refrigerators in rooms 4, 46, and 38. **All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b).

Observed stained carpeting in several rooms. Grout in shower of spa room discolored, needs better cleaning.**Keep all flooring clean. 15A NCAC 18A .1309 (a).

Observed non-slip strips in shower in room R-41 lifting. Torn shower chair, R45. Soiled shower chair, spa. Shower chair in disrepair in R-21. Rusted toilet chair R-8. Cabinet damage R-8.**Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).**Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).**Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)

Observed single service cups and pill cups not protected from contamination on med cart.**Unused medication cups shall be kept covered or inverted. 15A NCAC 18A .1318 (c).

Observed: Clean linen stored with non linen related items in hall linen closets.**Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. 15A NCAC 18A .1319 (b).

Repeat Non-Compliance: -Observed soiled toilet seats and/or bowls in D16, C29, and D Hall spa.-Observed stained shower cover in C42. Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).

-Repeat Non-Compliance: Observed briefs stored on the floor in several rooms.All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).-Observed briefs, towels, toothbrushes, etc were stored under the handsinks in several restrooms.Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a).

Repeat Non-Compliance: Observed no thermometers in the refrigerators in rooms A8, D20, and C29.All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b).

Observed: Mold/mildew collecting between the shrink wrap and the bottom of the shower chair and the vinyl on the shower chair damaged in room 25. A dirty bedside commode frame in room 48. A dirty bathing chair in the Spa. A damaged toilet seat in room 18. Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).

Observed: Hats stored on the closet floor. Cabinets and drawers collecting hair in the Salon. Resident tooth brushes stored in the splash and drip area at hand sinks in rooms.All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).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).

Observed: Clean linen stored with non linen related items in hall linen closets.Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. 15A NCAC 18A .1319 (b).

Observed: A damaged thermometer in the Avery Place fridge. No thermometer in room 18.All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b).General Comments: #9: A bedpan not labeled in room 4. **Label all bedpans with the name of patient and date provided.Jason Charrette present.

Observed shower chairs with damage in rooms 45, 25, and 7. Stained/soilled shower chair, shower room. Soiled shower curtain in shower room. Hair and product build-up in and behind wash basin in beauty salon. Pink residue around hand sink drain in PT. Pink ring in toilet bowl, room 25. Wipe cabinets in spa room and laundry room. **Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). **Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). **Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)

Observed diapers stored on floor in room 25. Personal items stored below hand sinks in resident rooms shoould be protected. Boxes stored on floor in closet near kitchen. **All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). **Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a).

Observed unapproved wipes being used to disinfect PT table. Use approved wipes. **Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).

Observed no thermometer in resident room refrigerators. **All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b).

Observed torn shower chair, room 45. Finish torn on bathroom cabinet, room 45. Leak at plumbing in hopper room. Sink and cabinet below sink in med room with build-up.15A NCAC 18A .1312 TOILET: HANDWASHING: LAUNDRY: AND BATHING FACILITIESFixtures and furnishings shall be kept clean and in good repair.

Observed water fountain with too high of water pressure, splatters onto carpeting. One water fountain has corroded nozzle.15A NCAC 18A .1314 DRINKING WATER FACILITIES: ICE HANDLING(a) Drinking fountains shall be of sanitary angle-jet design, kept clean, and properly regulated.

Observed boxes on floor in couple storage rooms. Personal drinks stored with single service supplies. Puzzles stored below hand sink. 15A NCAC 18A .1318 MISCELLANEOUS(a) Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture and supplies, and kept clean. All patient care or consumable items shall be stored at least eight inches above the floor to prevent water contamination from cleaning floors and shall not be stored below exposed sewer lines.

Observed pill crusher on sharps container. Unprotected single service cups on top of med cart. Personal drinks on top of med cart. One med cart unlocked and unattended.15A NCAC 18A .1318 MISCELLANEOUS(c) Medication carts shall be cleaned when visibly soiled. Food and utensils used on medication carts shall be handled in a sanitary manner. Unused medication cups shall be kept covered or inverted. Sharps containers on medication carts shall be affixed or secured to prevent spillage.

Observed frayed mattress, room 7. Couch cushions in common areas had trash and medication under them. Beauty salon had cart with excess hair on it.15A NCAC 18A .1319 FURNISHINGS AND PATIENT CONTACT ITEMS(a) 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. Mattresses shall be kept clean, dry and odor free.

Observed water stored on floor in activities closet.15A NCAC 18A .1323 FOOD PROTECTION(c) Containers of food shall be stored above the floor, on clean racks, dollies, slatted shelves, or other clean surfaces in such a manner as to be protected from splash or other contamination.