MATTHEWS HEALTH & REHAB CENTER

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 damage to floor in Central bath 200 where liquid is seeping up through the floor and some damage to the floor near the wall. Observed damaged floor in shower room 300. Observed floor damage to 400 hall central bath. REPEAT.

.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 stained ceiling in 504, 420, 404, 100 hallway, and 116. 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 damaged shower tile in 100 central bath. Needs repair/caulking. REPEAT. Points reduced due to improvement.

.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed walkers and a wheelchair stored in 200 hall central bath. Bathrooms shall not be used for storage. 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 in excess of 120F in numerous rooms in the facility. Needs to be 105-116F. Staff has been keeping logs of regular checks for water. The facility may need to check more often.

.1314 (c) Ice machines and storage chests accessible to residents, guests, or the public shall provide ice through automatic ice dispensing equipment and shall not permit ice to be accessed using a scoop or bucket. Observed cooler with ice store in hallway. CDI - Cooler with ice was moved to nurses room.

.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 stained chair in room 116. Observed build up on bed railing in 105. Needs cleaning.

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 damaged flooring throughout facility to include; central spa units 200 and 400 and shower room on unit 300.

.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 scuff markings to walling throughout facility. -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 loose toilet seat in room 126. Observed cleaning needed to toilet in room 311. Observed debris build up under blue shower mat located in central spa on unit 400. REPEAT VIOLATION.

.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed furniture and yellow bin for soiled clothing stored in units 100 and 200 central spa room.

.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 trash/litter surrounding dumpster area. -General comment.

.1319 (b) A resident's bed linens shall be changed when no longer clean. Observed stain on pillow case and blanket in room 107. Observed stain on sheets in room 302.

.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. Facility had no documentation during time of inspection to verify that notated rule is in compliance. EHS advised facility to start keeping a service report from their machine servicer. -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 broken tiles in showers of shared baths. Observed build up in grout on shared baths. Observed broken shower head in room 408. Needs repair.

.1312 (c) Disposable bedpans, emesis basins, and urinals shall not be used by more than one resident. Observed urinals and bed pans not labeled in bathrooms of shared rooms. Needs labeling. 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 in 301 at 121F, in 305 at 125F, in 322 at 121F, and at 118F in 102 and 106. Needs to be 105-116F. 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 incomplete back up water supply plan. Administrator filled out template during inspection. 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 some staining on common area furniture.

.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 activity room refrigerator missing thermometer. Needs thermometer.

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 baseboards in need of repair shared spa rooms. Observed floor tiles cracking and in need of repair in shared spa rooms.

.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 a couple stained ceiling tiles missing in shared spa room on 100 hallway. -General comment.

.1312 (c) Disposable bedpans, emesis basins, and urinals shall not be used by more than one resident. Observed 1 urinal not labeled in room 132. Improvement made from previous report. -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 not within range in several rooms throughout building. Room 103, 121F; room 106, 120F, room 114, 121F, room 207, 135F, room 132, 124F, and room 303, 92F.

.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 required procedure plan. -General comment.

.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/litter behind dumpster area, improvement made from previous report.

.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 stored in nourishment units and 100 and 200 hallways not labeled in accordance with notated rule. -General comment.

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 floor tiles cracking throughout facility to include the following areas: 200 central bath, 300 central bath, and 400 central bath.

.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 wall damage to several rooms throughout facility.

.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 handwash sign at employee restroom located near unit 400 nurses station. Improvement made from previous report.

.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’s not individually labeled in the following rooms: 117, 210, and 407.

.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 reach 124F in room 210, 120F in room 209, 119F in room 131, and 98F in room 407.

.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. During time of inspection, facility was unable to access their back up water supply plan.

.1314 (c) Ice shall be protected against physical, chemical, and biological contamination and shall be kept clean. Observed ice stored in non food grade trash bags throughout facility. EHS advises facility to obtain food grade ice chest liners instead of using trash bags to line ice chest.

.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 chair and debris/litter surrounding dumpster area.

.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. EHS advises facility to have chemical/machine service company to detail how much bleach or sanitizer is being pumped into system according to notated rule on future service reports.

.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 400 nourishment area refrigerator.

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 cracked floor tiles sporadically throughout facility. Observed 1 floor tile cracked in 200 central spa. Observed 300 shower room with floor tile cracking. Observed floor cracking in shower located in room 317.

.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 stained ceiling tiles sporadically throughout facility. EHS advises facility to ensure no active leak is occurring and to have stained ceiling tiles replaced/repaired.

.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 seat in the following rooms: 134, 302, and room 407.

.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 handwashing signs missing in several restrooms that employees use within facility to incldue the following areas: Small gym restroom, staff women’s locker room restroom, and men’s/women’s restrooms located on hallway near kitchen.

.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 disposal urinal not labeled in the following rooms, 302 and 307.

.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 not within required range throughout facility. Room 126, hot water 123F. Room 202, hot water 123F. Room 134, hot water 121F. Room 307, hot water 99F. Room 407, hot water 99F.

.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 administrator, Mike McSwain, a template for back up water supply plan.

.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 mattresses stored behind dumpster. Per conversation with head of maintenance, mattresses are scheduled to be removed soon.

.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 1 geriatric chair stored in 100 shower room with the arm rest peeling and in need of repair.

.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed heavy slimy black/pink build up on ice machine chute located in 300 nourishment area.

.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. Per conversation with nursing staff, the water they are using to fill up water pitchers on their carts is being obtained from a handsink in nourishment room areas. EHS advises facility to obtain drinking water from an approved source (food preparation sink in kitchen, water fountains, bottled water. Drinking water should not be obtained from a handwashing sink).

.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 stored in nourishment room kitchens with either no name or dates only. EHS advises facility to follow notated rule (nourishment rooms on unit 100 and 400).

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 damaged flooring in spa rooms.

.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 scuffed walls where wheelchair have hit it. Doors and door frames with chipped paint. Exterior doors with corrosion. Laundry room ceiling with moisture damage to paint. 200 hall wall damage in custodial closet.

.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 plumbing leak 200 hall spa. 2 hand sinks leaking from the fixture.

.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 hand sink on soiled side of laundry room has been removed. Hand sink needs to be reinstalled.

.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 staff not using disinfectant correctly. Other staff could not explain how to use the disinfectant properly.Repeat- Disinfectant that is not health care approved being used in PT.

.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. REPEAT-Observed hot water ranged from 85-122F. Some of the faucets spiked >120F then came back down. Hot water >120F is a scald hazard. Administrator said the mixing valves are being adjusted daily. Mixing valves should not have to be adjusted very frequently. Have system evaluated for mixing valve replacement or back-siphonage from a broken check valve/backflow preventer, or both.

.1314 (c) Ice shall be protected against physical, chemical, and biological contamination and shall be kept clean. Repeat-Observed ice in plastic bags inside ice chests.

.1318 (a) Medication carts shall be kept clean. Observed debris in med cart drawers and pill crushers.

.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 debris under cushions in common area. Chair torn in beauty shop. (Lots of improvement)

.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 vomitus clean up plan. (New rule). supply above items including the clean up plan on how to use the above referenced supplies.