ROYAL PARK REHABILITATION & HEALTH CENTER

Inspector comments: *NOTE: Head of housekeeping, Samantha Dunkin, was present during time of inspection. Intern EHS, Isabel Self, was present during time of inspection. Report emailed to Administrator, Nicola James, at the following: Nijames@liberty-ltc.com

Inspector comments: *NOTE: Report emailed to administrator, Nicola James,following: Nijames@liberty-healthcare.com

Inspector comments: *NOTE: EHS, Olivia Young, was present during time of inspection. Report emailed to the following: Nijames@liberty-healthcare.com DLight@Liberty-Ltc.com

Inspector comments: Report emailed to ED, Nicola James, at: Nijames@liberty-healthcare.com

Inspector comments: *NOTE: Inspection was lead and typed by EHS, Anglecia Askew

Inspector comments: NO POINTS FOR THE FOLLOWING VIOLATIONS: #8. Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed rust build up on toilet chair in room 605. #9. Toilet rooms shall not be used for storage. See rule .1312 (b). Observed storage in shared spa room located on unit 500. Storage included a wheel chair and plastic rollers for soiled laundry. #26. The premises shall be kept neat, clean, and free of litter. 15A NCAC 18A .1317 (c). Observed dilapidated furniture stored behind dumpster enclosure. #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 staining on bed linen in rooms 506 and 605. *NOTE: Head Maintenance, Ryan, was present during time of inspection. Report emailed to him at: Dlight@liberty-healthcare.com Cflowers@LIBERTY-LTC.COM

Inspector comments: NO POINTS FOR THE FOLLOWING VIOLATIONS: #3. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed general wear and tear on walls throughout facility. Observed scuff marks on wall of room. #8. Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed toilet chair with rusting in room 507. #16 Observed an incomplete backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f). EHS emailed facility a guidance template. #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 documentation detailing the concentration strength of sanitizer being used within commingled laundry. 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 clean linen in storage areas on carts stored with cleaning materials and disinfectant wipes. Observed clean linen cart with discarded coffee cup underneath separation barrier. *NOTE: EHS Jordan McClenic lead inspection. Head of Maintenance Ryan Light was present during time of inspection. Report emailed to facility along with back up water supply guidance at: Dlight@liberty-healthcare.com Cflowers@LIBERTY-LTC.COM

Inspector comments: #8 Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed dead insects in bathing equipment in spa room near 600 hall that PIC stated was not currently being used. Regularly clean bathing equipment when visibly soiled. #9 Toilet rooms shall not be used for storage. See rule .1312 (b). Observed items stored in Rehab spa room that was not being used per PIC and utility cart stored in shower of room 514. CDI - Staff placed storage sign on rehab spa room. #21 Solid waste containers, rooms, or designated areas shall be kept clean. 15A NCAC 18A .1316 (c). Observed several storage rooms with debris and used gloves on the floor. Regularly clean floors of storage and linen rooms. #27 Maintain adequate vet records for all animals. 15A NCAC 18A .1317 (f). Observed resident with small dog. Facility did not have vaccination records available at time of inspection. Provide pet vaccination records and keep at facility. #28 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 boxes of wheelchair pads stored on bed in rehab room. Per staff the bed was not being used and shipment was received Friday afternoon. Staff stated the wheelchair pads would be labeled and distributed today. EHS recommended using storage rooms for delivery items not beds that may be used for residents. #30 Sharps containers on medication carts shall be affixed or secured to prevent spillage. 15A NCAC 18A .1318 (c). Observed one medical cart with sharps container not affixed. PIC stated affixed units for sharps container will be ordered for all medical carts. Inspection was lead by Mia Lowery #3040

Inspector comments: NO POINTS FOR THE FOLLOWING VIOLATIONS: #9. Toilet rooms shall not be used for storage. See rule .1312 (b). Observed furniture stored in shower rooms. #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 staining on bed linen in room 114. No points deducted due to major improvement from previous inspection report.

Inspector comments: GENERAL COMMENTS NO POINTS FOR THE FOLLOWING VIOLATIONS: #9. Toilet rooms shall not be used for storage. See rule .1312 (b). Observed several large boxes stored in spa room located near beauty salon. #18. Label all disposable water pitchers with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a). Observed residents pitcher not labeled in room 114. #35. Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c). Observed hair build up in rollers located inside of beauty salon. #43. All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b). Observed refrigerator thermometer missing in room 108. *NOTE: report emailed to Administrator at trocquemore@liberty-ltc.com

Inspector comments: NO POINTS TAKEN FOR THE FOLLOWING VIOLATIONS: #8. Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed soiled tiolet in spa room on hall 500 and in room 305. General Comment. Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed soiled shower chair in rooms 305 and 607. Observed shower curtian in room 210 soiled. #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 hot water temping at 120F in room 607 and 118F in room 506. #18. Label all disposable water pitchers with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a). Observed disposable water pitchers in rooms 607 and 404 with no label. #35. Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c). Observed torn pillow in room 108. #36. Cooking surfaces of equipment shall be cleaned at least once each day. 15A NCAC 18A .1320 (c). Observed microwave with heavy food residue on 200 hallway nourshiment kitchen. #43. 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 room 404.

Inspector comments: NO POINTS #12: Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). Observed no paper towels at 1 sink in soiled utility room. CDI-replaced #15: Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d). Observed no backflow preventer on shower wand in room 108. #16: 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. Observed incomplete back-up water supply plan. **#8 points taken Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed shower bed with debris, 100 hall spa. Observed most shower chairs with undersides soiled. Some shower chairs had soiling on chair surface or in holes on seat. Clean all shower chairs thoroughly. Observed shower curtains soiled throughout in several resident bathroom within rooms. Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed toilet needs old caulking replaced around base, room 108. Several toilet chairs soiled under seat or on toilet base under chair. Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b) Observed build-up in and around sinks in med rooms. Observed backsplash swollen and pulled away from wall.

Inspector comments: NO POINTS #1: **Keep all flooring in good repair.  See rule .1309 (a) and (b). Observed flooring lifting and damaged. In process of being replaced. **Floors shall be free of obstacles to cleaning.  See rule .1309 (a). Observed storage on floor. Keep storage off floor to keep floor accessible for cleaning. #25: **All pesticides shall be handled and  stored in a manner that avoids health hazards.  See rule .1317 (b). Observed can of Raid roach and ant spray in clean utility room. Store pesticides where they are not accessible. If having pest issues contact is licensed PCO. #28: **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 cart used for foot care/Pediatrist with opened drinks, opened food, trash, used gloves and used (small scalpel looking device) sharps. Sharps are single use only and should be disposed of after use. Call for reinspection when ready 980-314-1620 to put in a service request to main office

Inspector comments: Escorted by Frank Taylor; report received by Howard Staple NO POINT DEDUCTION FOR THE FOLLOWING: 11. Observed a pile of ice inside the service kitchen hand washing sink. **Hand washing sinks are for hand washing only. 14. Observed new "Maintenance Solution Fresh Breeze Neutral Disinfectant & Detergent" is not labeled for use in institutional facilities as a disinfectant. Discussion with product representative stated the product is an air freshener ONLY. New product was not yet in use, and housekeeping carts were supplied with Spartan Disinfectant. Observed no disinfectant stored in the spa rooms, however, the staff stated the disinfectant was accessible on housekeeping cart and housekeeping closets when needed. **Provide training for all staff responsible for cleaning and disinfecting skin contact bathing equipment. 28. Observed an air mattress was stored on the floor in the equipment room (600 hall). **Patient care and contact items must be stored above 8 inches of the floor. 30. Observed single service drinking cups were over stacked and were not covered/protected on the 500 and 600 hall med carts. **Drinking and eating utensils must be covered. 33. Observed the label on the soiled linen bin in the beauty salon was worn off, and the soiled linen bin (clothing protectors) was not labeled as "soiled linen" in the dining room. **Label all carts/containers "soiled linen". 43. Observed the facility issued refrigerator was at 56F in room 322. Only commercially packaged juice was stored; there was not potentially hazardous food stored inside the refrigerator. **Ensure refrigeration temperature is below 45F. Also, observed temperature logs for resident room refrigerators were used incorrectly (same temp logged for each day, temp logged pre-fill through 2/17). **Ensure the actual internal temperature of the refrigeration unit is documented on the log so intervention can be made of the unit is not a sufficient temperature. Provide in-service training for staff monitoring refrigeration temperatures.

Inspector comments: Escorted by Cleveland Williams and Frank Taylor. Report received by Howard Staple (administrator) NO POINTS WERE ISSUED FOR THE FOLLOWING: 4. Observed lights were not working in 400 hall lift storage and physical therapy restroom , and the light shield in the soiled linen room was not secure. **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). 12. Observed no soap at the hand washing sink in 300 hall service kitchen and 300 soiled utility room. **Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). 10. Observed bedpans were not labeled in rooms 615, 503. **Where bedpans are cleaned in patient/resident rooms, bedpan cleaning facilities shall consist of a water closet with bedpan lugs or spray arms. 15A NCAC 18A .1312 (c). 14. Observed no disinfectant supplied in the 500 hall spa room. Post procedure for cleaning the spa tub in each spa room. **A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). 21. Observed litter and fallen debris/trash in the ground surrounding the dumpster. **The rooms, enclosures, designated areas, and containers shall be adequate for the storage of all solid wastes accumulating on the premises. 15A NCAC 18A .1316 (c). 34. Observed a disposable brief were stored with clean linen in physical therapy. **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). 40. Observed a container of personal food was not labeled in the 600 nurishment room. **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). 43. Observed no refrigerator thermometer in the 600 hall nourishment room. **All refrigerators shall maintain a temperature of 45°F or below. 15A NCAC 18A .1323 (b).

Inspector comments: Mr. Cleveland and Mr. Frank were present during the inspection today. Recommendation given to ensure that bedside urinals are labeled with resident name. 2)Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed carpet in common area 600 to have significant staining. Observed lift storage room with tile lifting. 18)Label all disposable water pitchers with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a). Observed some water containers where label has worn off. 25) All pesticides shall be used as directed on the product label. 15A NCAC 18A .1317 (b). Observed pesticides labled "for household use only" being used in facility.

Inspector comments: Mark Farran (administrator), and Cleveland (maintenance) were present during the inspection. NO POINT DEDUCTION 3. Observed the walls were splattered/stained in the entrance hallway, and door frames with damage. Improvement since last inspection **Keep all walls and doors ion good repair. 4. Observed the light was not working in the housekeeping closet in 500 hall, and the large lobby light with debris. **Keep all lighting clean and in good repair. 30. Observed one med cart with overfilled drinking cups that were not protected. **Keep all drinking cups protected on med carts. 34. Observed the new clean linen cart covers are mesh material that does not protect against contamination when stored on the hallway. **Store all clean linen so that they are protected from contamination. 36. Observed the microwave was not clean in 300 nourishment and the service kitchen refrigerator with a sticky residue. **Keep all food service equipment clean.

Inspector comments: .11 Handwashing sinks shall only be used for handwashing 15A NCAC 18A .1312(d) Observed handwashing sink in the clean linen closet with rice and food in it, thus the handsink is being used as a dump sink. Advised to only use handsinks for handwashing. 13 The facility shall provide hot water within the temperature range of 100F to 116F 15A NCAC 18A .1312 (e). Observed the handsink water in the rehab room with a water temperature of 90F. 28 All patient contact items must be 8 inches above the floor 15A NCAC 18A .1318(a). Observed clean linens in the linen closet on the bottom rack that was not 8 inches above the floor. 32 All furniture, mattresses, sleeping mats, curtains, or other furnishings shall be kept clean and in good repair. In room 607, observed the drawer in the night stand torn on the inside and a torn comforter on the bed.34 If hot water is used to sanitize linens the linens shall be washed with a detergent in water at least 160F for 25 minutes. If low water temperature is used to wash linens, the linens shall be washed in at least 50 ppm chlorine or an EPA listed laundry sanitizer shall be usd in accordance with the manufacturer's instructions 15A NCAC 18A .1319 (b). Observed insufficient paper work for the sanitizer solution used for washing the linens. Advised to get paper work from the company that services the machine to provide paperwork that illustrates that the wash solution uses the correct part per million (ppm) solution.

Inspector comments: 28) 15NCAC 18A .1318 Store equipment and supplies at least 8 inches off the floor. Observed storage of loose pillows touching the floor hanging off storage shelves. Recommend storing items on lower shelves in plastic bags.

Inspector comments: John FIckers was present during the inspection.#3 - Observed the walls were damaged in room 117, and the baseboard coming away from wall in the physical therapy kitchen. **Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.#4 - Observed lights were not functioning in housekeeping closet (500), and the men's restroom in physical therapy. **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). #9 - Observed a food service cart was stored in the shower in room 218, and a box of equipment used for a resident's bed was stored in the Spa room. **Toilet rooms shall not be used for storage. See rule .1312 (b). #15 - Observed no backflow prevention device on the detachable shower head at the bathtub in the ADL shower. **Provide backflow prevention devices on each detachable shower head. **Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).#21 - Observed litter collecting on the ground at the dumpster area. **Solid waste containers, rooms, or designated areas shall be kept clean. 15A NCAC 18A .1316 (c).#24 - Observed 2 live roaches in the 300 hall nourishment room, and several dead on the floor. Also observed several drain flies in the service kitchen in the staff service hallway. **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).#34 - Advised by staff that facility will begin to launder linens on site. **Provide documentation for chlorine concentration at each washing machine. **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).#36 - Observed some residnet's personal refrigerators needed cleaning (rooms 117, 615). **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: John Fickers(administration) and Jimmy Davis (maintenance) were present during hte inspection. #2 - Observed the floors with dried spills in the 600 wing private dining room, and in the 500 utility hallway. **Keep all flooring clean. 15A NCAC 18A .1309 (a).#13 - Observed the hot water at the hand washing sink was 118F and 117F in rooms 403 and 408. **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).#14 - Ensure that all community showers/Spa rooms are supplied with disinfectant soultion for use after each resident. **A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).#21 - Observed some litter/fallen debris was collecting around dumpster area and the doors were left open. **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).#30 - Observed drinking cups on some medication carts were not covered. **Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c).#34 - Laundry is currently out-sourced.#36 - Observed some microwaves with food debris. **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).#43 - Observed the facility supplied refrigerators were not supplied with thermometers. **All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b).