LAKESIDE HEALTH & REHAB CENTER

REPEAT 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 bathroom floor peeling/damaging in room 312, Observed back up drain from freezer in kitchen's floor need repair. Point remain the same at this time.

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 damaged walls in residents room by headboards throughout, wall next to shower in 305. Observed hand sink and wall separation in spa room 100 hall, laundry room, restroom near gym1/100 hall, 707, 312. Observed damaged ceiling and disrepair paint in back service hall. Observed dust cover restroom vents throughout need cleaning. Checking for leaks on the roof and ceiling, repair, replace as necessary. Keep clean and good repair.

General Comment: .1312 (b) Bathrooms shall not be used for storage of items not currently in use.- Observed wheelchairs, pillows stored in the spa rooms. ONLY bathroom related items are allowed in the spa room.

General Comment: .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 individual urinal in couple restrooms without labeling.

REPEAT .1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices.- Observed no paper towels and/or soap available at hand sink in clean linen room Copper Ridge and Hunting Brooke station, 300 hall Spa room, medical supply room, 700 hall Spa, soiled utility room and restroom in Hunting Brooke hall. Ensure to provide all hand washing supplies at all hand sinks at all time. NOTE: ***Do NOT block the pathway to hand sinks for hand washing at anytime anywhere in the facility.***

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 throughout the facility measured between 119F to 123F. Provide tempered water between 105-116F at any times.

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 the facility has incomplete written plan. The facility shall put the plan together and have a complete plan available upon request.

General Comment: .1317 (a) Pests shall not be present in an institution's building or buildings.- Observed drain flies in the kitchen.

REPEAT 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 bathroom floor peeling/damaging in room 305 and 312. Observed damaged/stained shower floor in 614, Repair, resurfacing needed.

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 damaged walls in residents room by headboards throughout, shower room wall. (602, 607, 703, 108, 403,..) Observed hand sink and wall separation in spa room 100 hall, restroom near gym1/100 hall. Needs repair.

General Comment: .1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices.- Observed no paper towels and soap at hand sink in clean linen room 300 hall, no paper towels at hand sink in soiled utility room 500 hall. Ensure to provide all hand washing supplies at all hand sinks at all time. NOTE: Do not block the pathway to hand sinks for hand hygiene at anytime. Ensure to provide access to hand washing in all the utility rooms.

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 at 125 in room 607, 122F in room 614. Needs to be 105-116F. No point deduction at this time due to major improvements from previous inspection.

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 the facility has incomplete written plan. EHS email the checklist to administrator. The facility will put together a complete plan and have it available upon request.

.1320 (a) All food service equipment and utensils shall be kept clean and in good repair.- Observed soiled microwaves in nourishment rooms need cleaning. Soiled refrigerator needs cleaning, broken ice machine needs repair in nourishment room 500 hall.

REPEAT .1323 (a) All TCS food shall be maintained at temperatures required by Part 3-501.19 of the Food Code incorporated by reference at 15A NCAC 18A .2650 as amended by 15A NCAC 18A .2653 during storage, preparation, transportation, display, and service of the TCS food. Observed tuna, ham/cheese sandwiches in refrigerator in nourishment room measured above 41F. All TCS foods shall maintain the safe holding temperature at 41F or below. CDI- Kitchen staff discarded items at the 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 damaged walls in residents room by headboards throughout. Needs repair.

.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 in shower of 315. Observed shower bed in 700 central bath in need of cleaning and green build up on one of the shower heads. Needs cleaning. 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 at 119-125 in 700 hall. Needs to be 105-116F. 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 fall pad in 302. Observed torn wheelchair in 307. Needs repair/replacement.

.1323 (a) All TCS food shall be maintained at temperatures required by Part 3-501.19 of the Food Code incorporated by reference at 15A NCAC 18A .2650 as amended by 15A NCAC 18A .2653 during storage, preparation, transportation, display, and service of the TCS food. Observed vanilla Med pass beverage on medication cart stored next to ice pack. Med pass was above 41F. Med pass is to be refrigerated after opening. Staff states it will stay on medication carts for up to a day after opening. EHS recommended using ice for holding Med pass after opening to maintain temperature over ice pack.

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 bathroom floor peeling in room 312. 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 scuffed/peeling walls throughout facility and in multiple resident rooms. Repair. 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 rusted toilet chair in rooms 305 and 404. Repair/replace. REPEAT *No escalation in points due to improvements from previous inspection*

.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 temperatures below 105F in spa rooms and rooms 612, 312, 305, and 404. Ensure hot water temps are between 105-116F. REPEAT

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 closets flooring need cleaning and tidy up, removed empty boxes of the floor.

.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 damaged wall trim/base board in 312. Need repair.

.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 toilets need cleaning in room 106, spa room in 300/100 hall. Observed shower floor/ grouting tiles need details cleaning in spa room 300 hall. Rusted toilet chair and slow drained at hand sink in room 312, repair or replace.

REPEAT .1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices. Observed soap and/or paper towel dispensers is not working causing no soap/paper towel available for hand washing at hand sinks in clean linen rooms, soil rooms, 100/300/700 hall spa, hair salon, and some residents room. Ensure to provide hand washing supplies and made available at all hand sinks at all time.

.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 the facility is using incorrect disinfectant/cleaner to clean the facility. The facility has the correct disinfectant/cleaner solution to use in stock, the administrator is correcting the action at the time of inspection. The housekeeper know the correct contact time for proper cleaning.

.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 2/3 of the facility water temperature range from 91F- 102F. Ensure to provide tempered water 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 the facility with an incomplete water back up supplied plan. EHS sent administrator a checklist plan and discussed details needed at the time of inspection. The facility is going to make a detail plan and put it together for next inspection. No point escalated.

.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 mattress in room 106, damaged wheelchair seat in 302. Need cleaning, replacing or repairing.

.1320 (a) All food service equipment and utensils shall be kept clean and in good repair.- Observed evidence of corrosions inside the ice machine in nourishment room near 700 hall. Need repair or replace.

.1310 (b) Light fixtures, fans, conduits, and heating, ventilation, and air conditioning vents shall be kept clean and in good repair. Observed room 604 AC air filter need to be cleaned and keep clean. Observed water stain on ceiling in back service hall, the facility has been working on fixing the issue.

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 hand washing sink was blocked (No access to hand washing) by big bins/medical supplies in clean and soil utility room. Refrigerator was blocking the hand sink in the med room on copper ridge hall/hunt on brook hall. Ensure to provide access to all hand washing sinks at all time. Observed loose toilet seat in room 712, 504, men’s room in the front service hall, in spa room on Hunton brook hall, Need repair and keep in good repair. Observed hard water stain on toilet in spa room on hunton brook hall, need cleaning. Observed broken/damaged/missing shower faucet knobs/shower head/handles, need repair or replace in spa room on hunton brook hall, spa room on 100 hall.

.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed roller bedside table stored in spa room hunton brook hall. Observed a pillow on a shower bed in spa room 300 hall.

.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices. Observed soap and/or paper towel dispensers is not working causing no soap/paper towel available for hand washing at hand sinks in clean linen rooms, soil rooms on hunton brook hall, copper ridge hall. Ensure to provide hand washing supplies and made available at all hand sinks at all time.

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 the facility with an incomplete water back up supplied plan. EHS sent PIC an example plan and discussed details needed at the time of inspection. PIC is going to make a detail plan and put it together for next inspection. No point escalating this time.

.1314 (a) Drinking fountains shall be kept clean and in good repair. Observed on of the water fountain on hunton brook hall with high water pressure. Adjustment needed.

.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 one of the dumpster is missing a drain plug, need a replacement.

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 food debris/dust underneath the sofa in a living room at front service hall. Need cleaning and keep clean. Observed stained, damaged/frayed corners of mattresses in room 504, 712, 601, 606. Observed damaged pillows in room 108. All item need to be cleaned and keep in good repair.

.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 the facility without laundry machine service records for sanitizing linens. PIC trying to reach out to a company and couldn’t be reached to obtain a record during the inspection. The facility will have all the records needed for next inspection.

.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed rusted microwave in a nourishment room copper ridge hall, need repair or replace. Keep in good condition.

.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 pimento cheese sandwiches in the refrigerator in nourishment room on copper ridge hall, date marking 6/6/23. CDI- PIC volunteers to discard items. Kitchen staff stated that they were made yesterday and put on the wrong date. Ensure to put a correct date and discard item when expired.

REPEAT .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 facility without Vomiting and Diarrhea plan and kit available at the time of inspection. V&D clean up poster provided at the time of inspection. The facility need to obtain a V&D clean up kit and made available in such an event. No point escalating at this time.

.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 damage and ceiling stains/damage several areas throughout building.

.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 shower in room 314 with loose caulking making hard to clean. Observed 2 spa rooms with showers out of order. Hand sink in soiled utility blocked, keep hand sinks accessible.

.1312 (c) When disposable bedpans, emesis basins, and urinals are reused, they shall be labeled so that they are associated with an individual resident. Note: new rules require emesis basins, urinals and bedpans to be labeled.

.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. Discuss how bathing and waste disposal with be accomplished. Discuss what steps will be taken if water supply is available but unsafe.

.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 ice chest in hallway. Ice chests cannot be left unattended

.1318 (a) Food, utensils, medications, and equipment used on medication carts shall be kept clean. Observed spoons on med cart stored with bowl side up. Store with handles up to protect eating surface

.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 mattress frayed in rooms 314 & 706. Bedside table in disrepair room 706. Shower chair needs bottom side cleaned in room 706 and spa room. PT beds in both PT 1 & 2 with frayed edges. Wheelchairs in hallway (possibly PT’s) with damaged arm rests.

.1319 (b) A resident's bed linens shall be changed when no longer clean. Observed soiled pillow and pillowcase in room 301.

.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. A written vomiting or diarrheal clean up plan is required. Items listed in the plan must be available.