CLEAR CREEK NURSING AND REHABILITATION CENTER

Inspector comments: *NOTE: Director of EVS, Bu-Nita Frindt, was present during time of inspection. Report emailed to: CCN56-ADMIN@CLEARCREEKNURSING.COM CCN56-HSKP@CLEARCREEKNURSING.COM

Inspector comments: *NOTE: Director of EVS, Bu-Nita Frindt, was present during time of inspection. Report emailed to: CCN56-ADMIN@CLEARCREEKNURSING.COM CCN56-HSKP@CLEARCREEKNURSING.COM

Inspector comments: No points for the following violations: #5 Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). Observed air vents with large amount of buildup in room #408 & 304-1 #10 Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c). Observed 2 bedpan not labeled for designated patient. #13 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 water temp on 400 hall at 95F in resident rooms. Maintenance supervisor adjusted temperature to 104F. #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 ripped pillow in room #803 #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 soiled linen on bed in Room #803

Inspector comments: NO POINTS FOR THE FOLLOWING VIOLATIONS: #3. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed ceiling damage on mid 100 hallway and outside of room 605. EHS advises facility to ensure no active leak is occurring and to have ceiling resurfaced. Observed minor touch up paint needed to walls and wall joints throughout. Per conversation with staff, facility is in the process of renovating 100 hall and touching up paint throughout facility. #16. Observed an incomplete backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f). EHS emailed Administrator a guidance document detailing all that needs to be outlined in backup water supply plan. #26. The premises shall be kept neat, clean, and free of litter. 15A NCAC 18A .1317 (c). Observed dilapidated furniture stored outside of dumpster area (doors, refrigerator). EHS advises facility to have items removed from dumpster area. #34. 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). Observed no documents detailing the concentration of chlorine or EPA laundry sanitizer being pumped into system. The requirement outlined in 15A NCAC 18A .1319 is 50 ppm chlorine. *NOTE: EHS Staci Clark was present during time of inspection along with Maintenance Romanell Report emailed to ED, Michelle Flowers, at ccn56-admin@clearcreeknursing.com

Inspector comments: Keep all flooring clean. 15A NCAC 18A .1309 (a). Sweep dust particles out corners at end of hall and common areas. Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). Observed dust on filter in AC vent in room #603. All other rooms AC vent filters were clean. Remove dust from filter on vents.

Inspector comments: NO POINTS FOR VIOLATION: #5. Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). Observed ceiling AC vents throughout facility with dust accumulation. Clean. #36. 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 both satellite kitchen microwaves in need of interior cleaning. NOTE: Please note that inspection was lead by Eric Edmiston with Alexis Welch present. Head Administrator Ken was present during time of inspection, report emailed to him at: CCN56-ADMIN@CLEARCREEKNURSING.COM

Inspector comments: GENERAL COMMENTS NO POINTS DEDUCTED FOR THE FOLLOWING VIOLATIONS: #9. Toilet rooms shall not be used for storage. See rule .1312 (b). Observed all shared spa rooms checked during time of inspection with chairs, wheelchair's, and other furniture stored within spa facility. #16. Observed no backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f). Observed no back up water supply plan within facility. EHS emailed back up water supply plan guidelines to facility. #17. Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a). Observed black and pink build up inside of water fountains located in front of therapy room. Clean. #30. Unused medication cups shall be kept covered or inverted. 15A NCAC 18A .1318 (c). Observed all unused medication cups on medication stored uncovered and exposed to contaminates of the air. **Inspection report signed by Ken Zielinski and emailed to ccn56-admin@clearcreeknursing.com

Inspector comments: No points were deducted for the following: 2. Observed the floor with staining behind the toilet and in the shower in room 506. Needs to be cleaned. **Keep all flooring clean. 15A NCAC 18A .1309 (a). 13. Observed water temperature reach 118-119F in one half of the building (100-400 unit). Ensure that water temperature falls within range. **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). 28. Observed pillows in plastic bags stored on the floor in the laundry room. Ensure that resident items are stored off the floor. **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). 35. Observed hair in roller in the beauty salon. Needs to be cleaned after each resident use. **Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).

Inspector comments: No points were deducted for the following: 3. Observed stain above ice machine on 500 Hall. Needs to be cleaned. **Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. 5. Observed dust build up on vent cover in salon. Needs to be cleaned. **Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). 30. Observed lip of cups exposed on the med cart on the 700/800 hallway. Ensure that cups are protected. **Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c). 36. Observed interior of microwave dirty in the service area on 300/400 hall and staining from leak in the cabinets in the service area on 300/400 and 700/800 hallway. Needs to be repaired. **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: 10. Observed one bed pan in Room 808 missing name and date. **Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c). 14. Observed disinfectant for spa tub needed in Spa 79. Spa is not currently being used. **A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).

Inspector comments: No Points Deducted: 1. Observed loose tile under shelving in Housekeeping Office. **Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b). 17. Observed pink build up on water fountains near front entrance. **Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a). 28. Observed boxes stored on floor under shelving in supply storage near 400 Hallway. Observed bottle of sanitizer stored directly with uncovered medicine cups on medicine cart on 700 Hallway. **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). 33. Observed soiled linen on resident's bed in room 410. Observed soiled linen container in Spa on 400 Hallway not labeled as such or covered. **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). 34. Observed bag of clean socks stored on the floor in the Laundry Room. **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).

Inspector comments: Roy Culp (Maintenance), and Thomas McNeal(EVS) were present during the inspection. Dan Goodwin accepted the report. 8. CONTINUED FORM PAGE 2 Observed the bathtub in the therapy restroom with several dead drain flies. **Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). No point deduction for the following: 9. Observed wheel chairs, sitting chairs, therapy wedge were stored in the 500 hall community spa. **Toilet rooms shall not be used for storage. See rule .1312 (b). Observed a damaged unreadable hand wash sink the women's main hall restroom. **Keep hand washing signs posted in all staff restrooms. 15A NCAC 18A .1312 (b). 12. Observed the sink without soap in the laundry room, and the paper towels were inaccessible in the med prep room (service hall). **Provide liquid soap and disposable towels at all hand washing sinks. 15A NCAC 18A .1312 (d). 15. Provide documentation that the hair bowl faucet in the salon is equipped with back flow prevention. **Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d). 16. Updated back-up water supply plan submitted and will be filed. 18. Observed the water pitcher on the med carts with sticky residue, and one staff member stated the water pitcher was rinsed with hot water only. **All multi-use drinking water utensils shall be cleaned and sanitized between users. 15A NCAC 18A .1314 (a). Observed 26. Observed cardboard, wooden pallets and other items collect around the recycling dumpster. **The premises shall be kept neat, clean, and free of litter. 15A NCAC 18A .1317 (c). 28. Observed boxes of paper towels and toilet paper were stored on the floor in the EVS, and personal items stored on the sink counters within the "splash zone" in shared resident room. **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). 33. Observed soiled sheet on one resident bed in room 207. 35. Observed hair left in hair rollers in the hair salon. **Patient contact items that become contaminated during use shall be cleaned and disinfected after each use. 15A NCAC 18A .1319 (c). 36. Observed the refrigerator gasket was separating from door in 300/400 kitchen. **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). 40. Observed resident food was not labeled in the 100/200 kitchen and 500/600 kitchen. **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).

Inspector comments: (NO POINTS DEDUCTED) 2. Observed residue on carpet in 700 lounge lobby. Carpet was cleaned on site. 18. Observed 100 staff station with debris build up around top side of water pitcher. Water pitcher was removed from site and sent to kitchen for cleaning. 26. Observed items collecting inside of recycle garbage area in need of tossing, placing in dumpster. 34. Observed ppm concentration of sanitizer at laundry was not provided by server. Ensure chlorine ppm is provided by server to ensure linen are properly being cleaned. Observed build up in dryer holes.

Inspector comments: (NO POINTS DEDUCTED) #5 Observed A/C vents collecting dust debris build up in 400 spa and 400 soiled linen. Keep ventilation equipment clean and in good repair. #12 Observed soap not present in room 505. Provide soap at all hand sinks. #18 Observed drinking cups located on cart not covered. Cups were inverted, but need to be covered. #30 Observed pill crusher collecting debris in need of cleaning on hall 600. Keep pill crusher clean and in good repair. #32 Observed stain on dividing room curtain in room 202. Observed small stains present on living room furniture in 300/400 living area. Observed ripped pillow in room 401. Keep all furniture items clean and in good repair. #36 Observed underside of ice shoot containing residue splatter in 100 satellite kitchen. Observed microwaves in following areas with debris collecting on topside: therapy, 500/600, and 700/800. Observed food debris collecting in 100 nourishment room freezer. Keep all food service equipment clean and in good repair. Ms. Coleen was present during inspection.

Inspector comments: #4 Observed light flickering in bathroom of room 704. Repair/replace lighting. #19 Observed slight residue build up at hallway water fountain nozzle in front of therapy room. #30 Observed build up in corners of container trays located on 200 hall med cart. Observed drinking cups slightly overstocked stored on of med cart on 200 hall. Observed cracked pitcher top located on med cart on 300 hall. **Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).**Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c).#36 Observed food debris/residue present in therapy fridge and microwave. Per operator fridge is used by staff. Observer soiled utensil (chocolate spatula) stored in cabinet of activity area 500 hall. Spatula was removed. All food and non food contact surfaces shall be kept clean and or sent to be wash, rinsed, sanitized when visible soiled. #44 Observed food (vital care) stored on floor in med room 28. Store all food above floor.Documents were observed for back up water supply, but not formally in written plan (per operator plan was sent to previous inspector) send written plan via email (Alex Torres) to keep on file. Ms. Coleen Anderson (Administrator) was present during inspection.

Inspector comments: 11: Evidence of plastic ware being cleaned in the 100/200 nourishment room sink. **This sink shall only be used for hand washing. The Rehab OT kitchenette sink and the coffee shop sink shall only be used for hand washing OR utensil washing for personal items). Recommend to provide signage for intended use and remove soap and paper towels if not needed. 14: Provide an EPA registered hospital grade cleaner/disinfectant in 300/400 whirlpool. 40: Ensure all food brought into the facility is both labeled and dated upon arrival. The 4 serving kitchens will be fully inspected with the main kitchen using Food Code and be reflected in the kitchen inspection. Some items in the 4 serving kitchens will still be inspected with the building and reflected in the building inspection. Latrese Owens and Roy Culp present during inspection.

Inspector comments: Colleen Anderson and Roy Culp were present during the inspection. **The 500 and 600 wings were not in use during the inspection.#2 - Observed some storage areas with accumulated dust on floors. **Keep all flooring clean. See rule .1309 (a).#12 - Observed no paper towels at the hand washing sink in the 300/400 food prep area. **Provide liquid soap and disposable towels at all handwashing sinks. See rule .1312 (d).#13 - Observed the hot water in room 304 was 98F, and 91F in room 403. Hot water in both rooms was corrected to 101-102F. **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).#15 - Observed backflow prevention device on hair washing/hand washing basin was not connected. Maintenance staff stated backflow prevention was built into the faucet. **Provide product description/spec for faucet and maintain these documents.**Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. Seer rule .1313 (d).#19 - Observed the ice machine drain was clogged in the 300/400 food prep area. **Ice machines, buckets, other containers, and scoops shall be maintained in good repair. 15A NCAC 18A .1314 (b).#34 - Ensure that commercial washers used for washing/sanitizing linen are properly calibrated. Maintain documentation from supply/service company. **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 .1319 (b).#21 - Observed the exterior dumpster was leaking, and some trash cans were over flowing in the spa restrooms. **All solid wastes containing food scraps or other decomposable materials shall, prior to disposal, be kept in leak-proof, non-absorbent containers, which shall be kept covered with tight fitting lids when filled or stored, or not in continual use. 15A NCAC 18A .1316 (a). **

Inspector comments: Coleen Anderson was present during the inspection. The facility had two residents at the time of inspection on the 100/200 wing.#2 - Observed some areas with construction dust on floors. **Keep all flooring clean. See rule .1309 (a).#14 - Observed the H2Orange2 cleaner/sanitizer for the spa tubs is not an EPA registered disinfectant. Provide an approved disinfectant for all spa tubs, and community/shared showers. **Skin contact surfaces of all shared bathing equipment shall be cleaned with a detergent solution and then disinfected with an EPA registered hospital disinfectant between patient uses. See rule .1312 (f). **A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. See rule .1312 (f).#15 - Observed backflow prevention device on hair wasing basin was not connected. **Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. Seer rule .1313 (d).#16 - Observed no back-up water supply plan. Back-up Water Supply Plan Checklist was issued. **Provide a written plan that meets all parts of .1313 (f). #12 - Observed no soap at the hand washing/hair wash basin in the salon. **Provide liquid soap and disposable towels at all handwashing sinks. See rule .1312 (d). #17 - Observed the water pressure was too low on the water fountains on the main hall (accross from PT). **Drinking fountains shall be kept clean and properly regulated. See rule .1314#34 - Ensure that commercial washers used for washing/sanitizing linen are properly calibrated. Maintain documentation from supply/service company. **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 .1319 (b). #35 - Observed Bio specimen refrigerator and centifuge machine (blood) was set up for use in the 500/600 med prep room with clean supplies; observed oxygen tanks were stored in the soile utility room on the 100/200 wing. **Soiled patient contact items shall be take to a designated area for cleaning and shall be stored separately from clean items. See rule .1319 (c).#43 - Observed no thermometer in the 500/600 wing nourishment room; the area was not yet in use. **All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. See rule .1323 (b).