VIA HEALTH PARTNERS

General Comment: .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 slow drainage at hand sink in women restroom hallway, and room 9 need repair.

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 water back up supply plan available upon request, according to maintenance the facility is still working to revise the plan and use correct terminology for intent of purpose (Portable water vs. non portable water). Revision of correct terminology needed. Have a complete corrected plan available.

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 damaged, torn, and frayed furniture in almost all the rooms. Repair/replace of the furniture. NOTE: Maintenance stated that new furniture is on the way to be replaced.

REPEAT .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. - Observed hot water temperature throughout the facility measured between 120F- 122F. Provide tempered water temperature between 105F-116F.

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 water back up supply plan available upon request, per previous inspection reports, the facility still needs to revise the plan and use correct terminology for intent of purpose (Portable water vs. non portable water). Revision of correct terminology needed. Have a complete corrected plan available.

General Comment: .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 damaged, torn, and frayed furniture in almost all the rooms. Repair/replace of the furniture.

.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 slow drainage at family kitchen hand sink. Repair needed.

.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. - Observed water temperature in room 16 sink and family kitchen sink measured at 118F. Provide tempered water temperature between 105F-116F.

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 water back up supply plan available upon request, per previous inspection reports, the facility needs to revise the plan and use correct terminology and intent of purpose use for portable water or non portable water. Revise and obtain a correct complete plan and have it available upon request during inspection.

.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 no water back up supply plan available upon inspection request, per last inspection the facility needs to revise the plan and use correct terminology for portable water or non portable water. And use them for the correct intent purposes. Obtain a complete plan and have it available upon request during inspection.

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 soiled tubs from previously used with soiled towels still in the tub, Hydro therapy room. Clean the area/equipment after each use.

.1312 (b) A sign shall be posted in each toilet room for institution employees, directing them to wash their hands after each visit to the toilet room and before returning to work.- Observed restrooms where staff have access to without hand washing signs. Hand washing posters provided at the time of inspection.

.1320 (a) All food service equipment and utensils shall be kept clean and in good repair.- Observed rusted microwave with some food debris at the ceiling in the hall kitchenette. Cleaning/repair/replace needed.

.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 Throughout facility walls in need of cleaning and touched up.

.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 in hydro therapy room that spa wasn’t clean. Please clean tub before use.

.1312 (b) A sign shall be posted in each toilet room for institution employees, directing them to wash their hands after each visit to the toilet room and before returning to work. Observed wheelchairs stored in bathroom in the room with broken bed.

.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 dumpster doors open when not in use.

.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 holes in the furniture throughout rooms checked.

.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 wall damaged inside room #7 in need of repair; Observed wall damage inside storage room in back hallway near kitchen.

NO POINTS DEDUCTED .1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed vent inside bathroom of room #7 in need of cleaning.

Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b). Observed flooring inside staff lounge room damaged with missing floor tiles and missing baseboards in need of repair. Observed missing tiles in laundry room in need of repair.

REPEAT Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed wall inside back storage room used for extra roll-away beds damaged in need of re-painting. (Half point deduction due to improvement)

Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). Observed outlet vents / grates accumulating dust build-up throughout in need of general cleaning.

Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed ceiling with a water stain inside resident room #5 in need of 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 minor tears in room 9. Ensure all furnishing are clean and in good repair. Replace chair if damage increases.

Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). Observed hand drying device missing from hand sink inside (soiled utility) room.

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 resident room (#1, #2) measuring 98F.

Toilet rooms / SPAs shall not be used for storage. See rule .1312 (b). Observed SPA / hydro therapy room having multiple PPE storage boxes stored within room.

REPEAT Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed large amounts of misc debris (trash , straws, stirs) collecting on floor between refrigerator and counter in small kitchenette / break room.

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). Observed microwave (inside surfaces) having old food debris collected in need of detailed cleaning.

Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed cobwebs, dead insects, debris on floors in storage and maintenance closets. Observed garbage and debris under pull out beds in patient rooms. Repair gap behind toilet in women's bathroom, service hall. Clean biofilm off floor drain cover for ice machine consensate.

Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed soiled shower chairs in patient rooms. Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed soiled toilet chairs. Disinfect thoroughly.

Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c). Observed soiled pill crusher. Keep clean

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 some stains on common furniture. Spills in drawers and cabinets. Repair damaged surfaces inside drawers of bedside tables.

Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b). Observed soiled linen carts not labeled.

Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply and shall be labeled with the name of the person to receive the food and the date the food was brought into the facility. 15A NCAC 18A .1321 (b). Observed some unlabeled food family member brought in. Make sure all foods brought in are properly labeled. Observed medication for staff in refrigerator with patient food. Keep medication stored by itself and below any food.

REPEAT Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed toilet seat very loose in need of repair in employee lounge bathroom. (POINTS NOT INCREASED DUE TO IMPROVEMENT)

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 misc debris collecting underneath reclining chairs in residents in need of cleaning.

REPEAT Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed dirty sheet in need of changing in resident room #11. (POINTS NOT INCREASED DUE TO IMPROVEMENT)

Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed flooring with debris, dirt, cobwebs and dead insects throughout.

Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed hopper with rings, toilet needed cleaning and leak in toilet of room 9. Observed scale build-up on all spray arm diffusers. Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b) Observed areas behind sink fixtures in non-patient rooms and laundry room soiled. Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observedf soiled shower curtain in room 9

Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). Observed no soap in women's bathroom, lobby. No soap or paper towels at laundry room hand sink.

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 heavy build-up on pill crusher in med room.

Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed torn pillows in several rooms. Stained bedding in rooms 9,16, 2,

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 bag of clean linen stored on floor, linen room

REPEAT 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 reclining chairs in all resident rooms collecting debris on metal framing located underneath cushions (can be seen when in the reclined position). Observed old tooth paste splatter on mirror vanity in lavatory of room #9 in need of cleaning. Observed misc debris collected underneath bottom drawers in dressers inside resident rooms in need of cleaning.

REPEAT Observed chemicals being store on high shelf above other patient care items in central supply. EHS recommended reorganizing storage. **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 cleaning needed on the bed remote of room 15. Observed hair in the bedside table drawer of room 6. **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 entrance to nursing station in need of construction being complete. Door in the process of being added. Observed wall stains in soiled utility storage throughout facility. Minor touch up paint needed throughout storage areas. Observed missing base cove molding near nurses station entrance. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.

Observed bed pans without date label and patient's name in room 9 and 11. Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).

Observed counter siding coming apart from the base near the floor in nursing area. Observed small damage to bed railing throughout facility and adhesive residue on bed in room 7. Observed geriatric chair in soiled utility and clean utility room that had damage to arm of chair. 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 hoppers and some toilets with rings. Clean more frequently or use a different product to remove rings. Hydro tub with residue on floor. **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 Soap dispensers out of batteries in two soiled utility rooms and soap almost out in hydrotherapy room. **Provide liquid soap and disposable towels at all hand washing sinks. 15A NCAC 18A .1312 (d).

Repeat: Observed water temperatures less than 100F in several areas throughout facility (Repeat). **Maintain the hot water at all resident accessible hand washing sinks and bathing facilities within the temperature range of 100°F to 116°F. 15A NCAC 18A .1312 (e).

Observed no documentation on how commingled linen is being sanitized by laundry machines (Repeat). Observed clean linen being stored with chemicals and miscellaneous items in hydro therapy room cabinets. **All common linen including sheets, pillow cases, absorbent pads, towels, and wash cloths provided by the facility must be sanitized between users with an EPA registered laundry sanitizer or by other methods described in 15A NCAC 18A .1319 (b). **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).

Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). Observed several dusty vents.

Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed common bathing/spa room not being cleaned frequently enough. Water had evaporated from toilet and scale on tub.

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 hot water less than 100F in most areas throughout building.

Observed dusty vents in med room and nourishment area. Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).

Observed bed frame dirty in room 14. Observed sofa sleeper with trash present on interior. Observed table sicky residue in room 2. 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 residue collecting on tub in hydrotherapy room.Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).

Observed microwave collecting debris on interior.Cooking surfaces of equipment shall be cleaned at least once each day. 15A NCAC 18A .1320 (c).

Repeat non compliance: Observed debris collecting on pull out sofa beds on rails in room 2. Observed pull out sofa cushions worn in 2 and 11. Observed white residue on end tables in room 2 and 11. Observed mattress cover worn/damaged in room 11.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 shower chair in room 14 collecting residue on underside.

Observed dust collecting on bed frames in rooms 2 and 14. Observed debris collecting on roll out sofa bed in rooms 2 and 14 along edge of cushion.

Observed storage of blow up mattresses, sheets and straps in hydro therapy room.Toilet rooms shall not be used for storage. See rule .1312 (b).

Observed bandage in pillow case in room 1.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 floor drain collecting black residue under ice machine in kitchenette.Observed dead insects in electrical closets, custodial closets, and mechanical closets.**Keep floors clean.

Observed residue collecting in ice chute.**Keep all ice dispensing equipment clean.

Observed bed pads and incontinence supplies stored on floor in vacuum pump room, room had no drop ceiling exposed water lines overhead.**Keep all patient contact storage off the floor and protected from contamination.