SHELBURNE PLACE

15A NCAC 18A .1607 All floors shall be kept in good repair. Observed cracked floor tiles in shared bathroom between bedrooms. Needs repair.

15A NCAC 18A .1610 (a) Residential care facilities shall provide toilet, handwashing, and bathing facilities that are available for use by residents and employees that are kept clean and in good repair. Observed calcium build up on sink faucet in small bathroom. Observed build up on small floor tiles in shower in shared bathroom between bedrooms. Needs cleaning.

15A NCAC 18A .1610 (b) The residential care facility shall provide each resident with soap and individual hand-drying towels. These hand-drying towels will be stored separately after being used. Observed no paper towels in one bathroom and paper towel dispenser not operating in another bathroom. Staff placed paper towels in bathrooms.

15A NCAC 18A .1617 (a) Furnishings, including furniture, curtains, draperies, and blinds, shall be kept in good repair. Mattresses shall be kept in good repair. Observed one cabinet door missing in the kitchen and build up in the bottom of some cabinets. Needs cleaning/ repair.

15A NCAC 18A .1608 (b) Wall (doors, windows and window trim) and ceilings and ceiling attachments (light fixtures, fans, and vent covers) shall be kept in good repair. Observed touch up paint needed to walling and baseboards throughout facility. Observed black build up on popcorn ceiling in closet of rear room. EHS advises facility to ensure no active leak is occurring and to have issue repaired.

15A NCAC 18A .1610 (a) All residential care facilities shall provide toilet, handwashing, and bathing facilities that are available for use by residents and employees. These facilities shall be kept clean and in good repair. Observed loose toilet seat in bathroom 2.

15A NCAC 18A .1611 (d) Residential care facilities shall provide water heating facilities. Hot water shall be provided at temperatures between 105F and 116F at handwashing and bathing facilities. Observed hot water ranging between 90F-93F at hand sinks in residents bathrooms. -New rule, general comment.

15A NCAC 18A .1617 (a) Furnishings, including furniture, curtains, draperies, and blinds, shall be kept in good repair. Mattresses shall be kept in good repair. Observed 2 knobs missing on dresser in bedroom 2

15A NCAC 18A .1620 (d) All food shall be stored as required by Parts 3-302.11, 3-302.12, 3-305.11, and 3-305.12 of the Food Code, incorporated by reference at 15A NCAC 18A .2650 as amended by 15A NCAC 18A .2653. Observed no thermometer in refrigerator portion of refrigerator but freezer portion had a thermometer. -General comment.

15A NCAC 18A .1621(d) the residential facility shall have gloves, personal protective equipment, disinfectant, individual disposable towels, and a coagulating agent onsite for employees to use and a written procedure for employees to follow when responding to a vomitus or fecal matter on facility surfaces. The procedure shall specify the actions that employees shall take to minimize the exposure of employees, residents, guest, food, and additional surfaces to vomitus or fecal matter. EHS emailed facility new required procedure plan, updated rules, and employee health policy. -General comment.

REPEAT Each resident will be provided soap and individual towels. These towels will be stored separately after being used. 15A NCAC 18A .1610 (b). Observed both paper towel dispensers in bathroom down the hall on the left empty. PIC refilled dispensers during inspection. Toilet, handwashing, bathing, and laundry facilities shall be kept clean and in good repair. 15A NCAC 18A .1610 (a). Observed automatic paper towel dispenser in Jack and Jill bathroom on the right does not dispense paper towel or batteries was out. Repair or replace automatic dispenser or replace batteries if applicable.

All floors shall be easily cleanable and shall be kept clean and in good repair. 15A NCAC 18A .1607. Observed dusty floor underneath the beds in all rooms. Need cleaning and keep clean.

Each resident will be provided soap and individual towels. These towels will be stored separately after being used. 15A NCAC 18A .1610 (b). Observed both paper towel dispensers in bathroom down the hall on the left empty. PIC refilled dispensers during inspection. Toilet, handwashing, bathing, and laundry facilities shall be kept clean and in good repair. 15A NCAC 18A .1610 (a). Automatic paper towel dispenser in Jack and Jill bathroom on the right does not dispense paper towel. Repair or replace automatic dispenser or replace batteries if applicable.

All rooms shall be well lighted by natural or artificial means. 15A NCAC 18A .1609 (a). In the bedroom at the end of the hall on the left, after turning light on in closet, light flickers continuously. Contact maintenance to have the wiring or bulb checked and or changed.

An indicating thermometer shall be located in each refrigerator. 15A NCAC 18A .1620 (a). Observed no thermometer in refrigerator.

Each resident will be provided soap and individual towels. These towels will be stored separately after being used. 15A NCAC 18A .1610 (b). Observed no paper towels in bedroom 2 shared restroom. Toilet, handwashing, bathing, and laundry facilities shall be kept clean and in good repair. 15A NCAC 18A .1610 (a). Observed minor staining at the bottom of shower curtain in restroom 2.

-Observed pink and black buildup on the bottom of the shower curtains in both restrooms. -Observed buildup on the toilet seat in the master bathroom. -Observed a loose toilet in the hall restroom. Toilet, handwashing, bathing, and laundry facilities shall be kept clean and in good repair. 15A NCAC 18A .1610 (a).

-Observed stained pillows in the master bedroom and on the single bed in the 1st room on the left side of the hall. All furniture, mattresses, curtains, draperies, and other furnishings shall be kept clean and in good repair. 15A NCAC 18A .1617 (a). -Observed a hole in the mattress pad in the master bedroom. -Observed lint balls from the dryer under the covers in the bed in the bedroom across from the master. Clean bed linen in good repair shall be provided for each resident and shall be changed when soiled. 15A NCAC 18A .1617 (b).

Observed raw eggs stored over ready to eat foods. Shelves are not spill proof. Store raw eggs stored below ready to eat food. (Facility provided a spill proof container where the eggs will be stored in the refrigerator.) **All foods, while being stored, prepared, served, and during transportation, shall be protected from contamination. 15A NCAC 18A .1620 (a).

Observed toilet seat loose in the bathroom in room 2. Needs to be tightened. Observed shower head with white build up in the hallway restroom. Needs to be cleaned. **Toilet, handwashing, bathing, and laundry facilities shall be kept clean and in good repair. 15A NCAC 18A .1610 (a).

Observed raw eggs stored over ready to eat foods. Shelves are not spill proof. Store raw eggs stored below ready to eat food. (Facility may place eggs in a spill proof container and stored anywhere in the refrigerator.) All foods, while being stored, prepared, served, and during transportation, shall be protected from contamination. 15A NCAC 18A .1620 (a).

-Observed debris in the utensil holder and in the bottom of the spinning cabinet. Clean. Non-food-contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. 15A NCAC 18A .1618 (c ). -Observed the laminate broken/missing on the side of the kitchen counter (raw wood exposed). Paint or seal. All equipment and utensils shall be so constructed as to be easily cleaned and shall be kept in good repair. 15A NCAC 18A .1618 (a).

Observed the shower head with pink residue in the hallway bathroom. **Toilet, handwashing, bathing, and laundry facilities shall be kept clean and in good repair. 15A NCAC 18A .1610 (a).

Observed a pillow case on a resident's bed was stained, some dresser knobs were missing on bedroom furniture, the chair rail with chipping paint near the kitchen table, and the surface was damaged on the living room recliner. **All furniture, mattresses, curtains, draperies, and other furnishings shall be kept clean and in good repair. 15A NCAC 18A .1617 (a). '

Observed the bathroom (laminate) floor was water damaged and was soft. **Repair flooring and subfloor. **All floors shall be easily cleanable and shall be kept clean and in good repair. 15A NCAC 18A .1607.x

Observed the floor vent (HVAC) with chipping paint and rust in bathroom (inside bedroom). **Repair or replace vent and maintain in good repair. **Ventilation equipment shall be kept clean and in good repair. 15A NCAC 18A .1609 (b).

Observed cabinets with flaking surface in kitchen. Keep surface clean and in good repair. Observed oven drawer collecting debris. Keep equipment clean and in good repair. **All equipment and utensils shall be so constructed as to be easily cleaned and shall be kept in good repair. 15A NCAC 18A .1618 (a). **Non-food-contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. 15A NCAC 18A .1618 (c ).

Observed pink build up on shower curtain in back left room & hall shower. Observed pink underside of shower chair in hallway restroom. **Toilet, hand washing, bathing, and laundry facilities shall be kept clean and in good repair. 15A NCAC 18A .1610 (a).

Observed stain on pillow in back left room, hole in comforter front right room, stain on pillow front left room. Keep all pillows, linen clean and in good repair. Observed dresser in closet back left room. Observed bed cover with stains front left bedroom. Observed dinning room curtain collecting residue. **All furniture, mattresses, curtains, draperies, and other furnishings shall be kept clean and in good repair. 15A NCAC 18A .1617 (a).

Repeat Non Compliance: Observed paper towels not present in back right hall restroom. Paper towels provided during inspection. **Each resident will be provided soap and individual towels. These towels will be stored separately after being used. 15A NCAC 18A .1610 (b).

Observed slight stain at top of comforter in back left bed room. Keep all linene clean and in good repair. **Clean bed linen in good repair shall be provided for each resident and shall be changed when soiled. 15A NCAC 18A .1617 (b).

Observed no soap and paper towles at one hand washing sink, and a paper towel disoenser was jambed at one restroom hand washing sink,**Each resident will be provided soap and individual towels. These towels will be stored separately after being used. 15A NCAC 18A .1610 (b).General Comment: Jenita Hooks was present during the inspection.

A: Observed the couch, love seat and chair in the Den with worn/peeling surface. **All furniture, mattresses, curtains, draperies, and other furnishings shall be kept clean and in good repair. See rule .1617 (a).B: Observed a pillow case in one of the resident bedrooms was soiled. **Clean bed linen in good repair shall be provided for each resident and shall be changed when soiled. See rule .1617 (b).

A: Observed the HVAC floor vent in the hall bathroom with rust (REPEAT). **Ventilation equipment shall be kept clean and in good repair. See rule .1609 (b).