CADENCE SENIOR LIVING AT MINT HILL

.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed black build up on A/C unit in A16. Needs cleaning.

.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 build up on hopper on A hall. Needs cleaning.

.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 memory care reading 50F. Needs to be 41F or below.

.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 scuffing on walls in Parlor on A Hall.

.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. REPEAT: plan provided is incomplete. Please provide above information in the plan.

.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 one loose toilet seat in Womens hall bathroom. Needs tightening. Observed toilet chair adapter separating and with build up in A8. Observed toilet adapter not attached and being used but in need of cleaning in B9.

.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 incomplete back up water supply plan. EHS emailed facility administrator and head of maintenance template to ensure all aspects of facilities back up water supply plan are notated. REPEAT

.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 food/beverages in Memory Care activity area refrigerator missing some names and date labels. Needs names and date food was brought to institution.

.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 not labeled in room D6. General comment.

.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 at 92F in room D6. All other rooms checked during time of inspection hot water was in required range. General comment.

.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 incomplete back up water supply plan. EHS emailed facility administrator and head of maintenance template to ensure all aspects of facilities back up water supply plan are notated.

.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 dilapidated furniture stored within dumpster enclosure area. General comment.

.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed cleaning need to shelving in memory care unit refrigerator. REPEAT VIOLATION.

.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 touch up paint needed to baseboards, door frames, and some walling throughout facility. Observed wall paint peeling in gym located on “A” hallway.

.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 the bottom of shower curtain with black/pink staining in room D12.

.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices. Observed no paper towels at handsink in bathroom of memory care unit rooms 2 and C7.

.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 incomplete back up water supply plan. EHS emailed facility template for back up water supply plan.

.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed detailed cleaning needed to shelving of refrigerator located in memory care unit. REPEAT VIOLATION.

.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 a container of food stored in memory care unit refrigerator not labeled and in activity kitchen refrigerator not labeled.

.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 no handwashing signs at employee restrooms located near “C” hallway. REPEAT VIOLATION.

.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed detailed cleaning needed to shelving of refrigerator located in memory care dining area. REPEAT VIOLATION.

.1321 (a) All food and food supplies provided by an institution for consumption by residents shall be from approved sources, stored, and handled as set forth in 15A NCAC 18A .2600. Observed apples stored on shelving on “D” hallway at snack grab-n-go station not individually wrapped/separated to avoid outside contamination. EHS spoke with kitchen staff during time of inspection and apples were rewashed and individually wrapped during time of inspection.

.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 markings on walling in bathrooms located in rooms C7 & C5. REPEAT VIOLATION.

.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 loose toilet seats in rooms C12 & A14. Observed detailed cleaning needed to toilets in “C” Wing Spa. REPEAT VIOLATION.

.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 no hand washing signs posted at handsink in shared spa room located on C wing. Per conversation with staff, employees and residents utilize restroom.

.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 staining on curtains located in room B12. Observed staining on chairs in common room located on B and C wings.

.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed microwave and refrigerator in need of detailed cleaning located in craft room on D wing.

.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 no thermometer in refrigerator located in the following areas: B and C wing kitchenette’s and D wing craft room.

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 flooring in the C wing auxiliary kitchen that was sticky to the touch from previously spilled liquids. Observed dropped food on bathroom floor in room B5.

.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 dried blood on storage doors in B wing. Observed scuffed and dirty walls in storage room in C wing and bathroom walls of C5 and C11. Observed several areas of smudged hand prints on doors, near switch plates, etc.

.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 buildup on toilet in Spa A. Observed loose toilet seats B7, Spa C, common women’s room in wing D. Bathing facilities in spas B were visibly dirty. Spa A was leaking.

.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices. Observed no disposable towels or alternative hand-drying device in A3, C5, C11, B5, or B wing nurse laundry room. .1312 (d) Handwashing facilities shall be located in an institution in accordance with 10A NCAC 13B .5411, 10A NCAC 13D .3201, 10A NCAC 13F .0305, .1304, and 10A NCAC 13K .1109, .1204, as applicable. Institutions that do not have a handwashing facility located in all areas required by this Paragraph shall not be required to install handwashing facilities if the institution has an approved hand hygiene program. Observed med storage with opened containers of pills. Room does not have a hand washing sink therefore all meds need to be handled at med cart.

.1312 (e) EPA registered disinfectants shall be used in accordance with the manufacturer's instructions. When EPA registered disinfectants are mixed and prepared by institution employees, a measuring device, chemical testing device, or the methods and devices prescribed by the chemical manufacturer shall be used to prepare the concentration of chemicals in accordance with the disinfectant's label and the manufacturer's instructions. Observed unlabeled spray bottles of chemicals. Label all chemicals when stored outside of original container.

.1312 (f) Bathing equipment that has contact with a resident's skin and is used by more than one resident shall be kept clean and shall be disinfected between resident uses. Equipment located within a bathing facility that uses a pump to move water shall be kept clean in accordance with the manufacturer's instructions. Observed no disinfectant in Spas open to use by more than one resident.

.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 temperatures below 105F in rooms A3, A12, A wing nurse station, Spa B, C5, C11, D4, D7, D wing common women’s restroom, and beauty parlor.

.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 dumpster storage open to pests with extensive debris surrounding outside of dumpster. Close doors and clean surrounding area to prevent harborage of pests.

.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 chlorine bleach being used to sanitize institution’s linens, but no means to test ppm. Testing log was observed on wall, but had not been filled out since 2020.

Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed shower curtains in rooms A11 and D11 with build up. Clean or replace. Observed showers in rooms A11 and A13 in need of cleaning. keep clean and in good repair.

Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c). Observed single-service cups on two med carts without protection from contamination due to over stacking. Stack below lip of holder or store inverted in food grade plastic bag. Observed one med cart with single-service spoons being stored with mouth contact side up. Invert utensils with handles up.

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 temperature in several rooms failing to reach at least 100F or reaching 100F after a prolong running time.

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 litter under sofa cushion in common area of C hall. PIC clean litter from sofa.

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 comforter on the floor in linen storage.

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 the refrigerator in rooms #A9; A6; C7; D7; & B Place thermometer in all refrigerators in residents' room.

Observed an incomplete backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f). *NOTE: Report emailed to Director at kalexander@cadencesl.com

Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed minor build up under toilet in room A6 observed minor toilet staining in room C5. Clean.