EASTOVER NURSING CENTER

.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/cracked tile walls in bathing rooms on West end. 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 bathing room with black buildup in shower. Keep clean.

.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 majority of rooms above 116F. Ensure hot water is between 105-116F.

.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/damaged walls and peeling baseboards in various areas throughout facility. Improvement noted. Observed splatter on bathroom door in room 111. Keep clean. 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 loose toilet seat in room 225. Observed buildup/rust around base of toilet in room 122. Observed torn chair in room 122. Observed black buildup in and around floor tile grout and minor buildup on shower head in Bathing room East 2. Keep clean. REPEAT

.1317 (a) Pests shall not be present in an institution's building or buildings. Observed one dead roach in room 111. Keep building free of pests.

.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 torn chair in room 122. Observed very worn wooden furniture provided by facility throughout resident rooms. In need of replacement.

.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/damaged walls throughout facility. Repair. REPEAT

.1311 (a) The areas interior to an institution's building or buildings shall be equipped with at least 10 foot candles of light at 30 inches above the floor. Observed bathroom light fixture not working in room 106. Repair. REPEAT

.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed dust buildup in a/c filters in all resident rooms inspected and several damaged/broken filters. Observed dusty vent in bathing room West 1. Repair/keep clean. 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 toilet in need of cleaning in room 217. Observed loose toilet seat in east bathing room 1. Observed rusted toilet chairs. REPEAT

.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices. Observed no paper towels in soiled utility rooms. Keep hand sink stocked with soap and paper towels at all times. REPEAT Points remain the same.

.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 all resident rooms inspected above 116F. Ensure hot water is between 105-116F.

.1314 (a) Drinking fountains shall be kept clean and in good repair. Observed rusted and soiled water fountain in the therapy gym. REPEAT

.1318 (a) Food, utensils, medications, and equipment used on medication carts shall be kept clean. Observed pill cups stored in container on side of med-cart. Container is not easily cleanable, protect med cups by putting in a clean container or baggie. REPEAT

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 damaged/missing floor tiles in west shower rm #2. Rip in floor in bathroom R119. Observed soiled shower rooms floors throughout the facility need detail cleaning and kept clean.

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 wall damage and stained ceilings throughout facility. Filling up holes in wall and touching up paint on wall throughout the facility needed. Keep all wall in good repair. Observed Laundry room ceiling covered with dusts, needs cleaning. Soiled utility west with mold growth on wall.

.1311 (a) The areas interior to an institution's building or buildings shall be equipped with at least 10 foot candles of light at 30 inches above the floor. Observed light fixtures not working in resident rooms over vanities, keep all light fixtures functional

Repeat-.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed PTAC units in resident rooms with moderate to heavy dust build up in filters.

.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 blocked hand sink in laundry room, keep accessible without having to move carts. Observed loose toilet seat in west shower room #2.Repeat- Observed torn shower bed mattresses, unclean shower bed(s) and mattresses. Rusted toilet chairs.

.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 unlabeled and soiled urinals/bedpans in R218, R227, shower room #2 west

.1312 (d) Hand washing facilities shall be equipped with running water and a tempering device. Observed no hot water at hand wash sink in west soiled utility room. .1312 (d) Repeat-Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices.Repeat- Observed no soap or paper towels in med room east, west shower room #2.

.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- Observed incomplete back-up water supply plan.

REPEAT .1314 (a) Drinking fountains shall be kept clean and in good repair. - Observed rusted and soiled water fountain in the therapy gym. Fountain on east hall not draining and backing up.

.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 broken drain plug in dumpster. Replace drain plug.

.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 container near dumpster corral holding water. Keep containers drained to prevent mosquito breeding.

.1317 (a) Pests shall not be present in an institution's building or buildings. Observed drain flies in both soiled utility room.

.1318 (a) Food, utensils, medications, and equipment used on medication carts shall be kept clean. Observed pill cups stored in container on side of med-cart. Container is not easily cleanable, protect med cups by putting in a clean container or baggie.

.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Repeat- Mattresses shall be kept clean, dry, and in good repair. Observed stained drapes and privacy curtains in majority of rooms checked. Many damaged bedside tables. Torn mattress in R218. Torn pillow in R218.

.1319 (b) Bed linens that are provided by the institution for use by residents shall be free from holes and tears. Repeat-Observed torn sheets in R218

.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. Repeat- Observed no thermometer in refrigerator in east med room.

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 damaged/missing floor tiles in east shower 2, east pantry under the refrigerator, in boiler room. Observed soiled shower rooms floor throughout the facility need detail cleaning and keep clean. Point remain the same.

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 wall plugs panel came off the wall in 118, damaged wall/missing based boards in 104, 109, 110, 212, laundry room. Filling up holes in wall and touching up paint on wall throughout the facility needed. Keep all wall in good repair. Observed Laundry room ceiling covered with dusts, needs cleaning.

REPEAT .1310 (b) Light fixtures, fans, conduits, and heating, ventilation, and air conditioning vents shall be kept clean and in good repair. - Observed flickering light on west wing hallway. No light in 109, the of restroom 104, and the staff restroom east wing. Need repair or replace.

REPEAT .1311 (b) Ventilation equipment shall be kept clean and in good repair.- Observed AC filters throughout the building covered with lots of dusts, need detail cleaning. Observed broken/missing AC filters in 221, 225, 109, 121, need repair or replacement.

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 soiled toilet in room 121, 101, the gym restroom need cleaning. Observed rusted toilet chair in west bath 1, 101, gym restroom. Observed loose/damaged toilet seat in 225, front entrance hallway restroom, restroom in the gym. Need repair or replace as see fit.

.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 restroom in the gym need hand washing sign. Hand wash signs emailed at the time of inspection

.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices. Observed no soap in west bath 2. Need refill. .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 washing sinkis not available for hand washing, it was blocked by food/tray/ supplies in west pantry, plastic bag/items inside the hand sink in west soiled room and Bio hazard room east wing, the bath bed blocked in front of the hand sink in west bath 1. Ensure not to block and provide access for hand washing at all hand sinks at all time.

.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 throughout the facility water temperature some part is within range and some part is up to 120F (room 118, 101, 216, 230). According to maintenance, the facility had an incident with their water heater. This Monday coming up 10/30/23, the company will be out to adjust and ensure the water temperature is within the required range.

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 without complete water backup supplies plan. EHS email the checklist for water backup supply plan to maintenance and administrator at the time of inspection. Obtain the complete water backup supply plan for the facility.

REPEAT .1314 (a) Drinking fountains shall be kept clean and in good repair. - Observed rusted and soiled water fountain in the therapy gym and soiled water fountain on west wing, need cleaning and keep clean.

.1314 (c) Ice shall be protected against physical, chemical, and biological contamination and shall be kept clean. - Observed ice cooler sat outside the pantry room east wing. When asked, staff moved the ice cooler in the lock pantry room at the time of 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 damaged wheelchair armrest in hall, and therapy gym. Tears blue table/bed in therapy gym. Observed damaged pillows in room 230 and damaged mattress in room 101. Need repair or replace.

.1319 (b) A resident's bed linens shall be changed when no longer clean. Observed soiled blanket/bed covered in room 230. Need cleaning. Observed soiled sheet in room 104, 101, need cleaning.

.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 the record of chemicals that use to sanitize the linens that facility provides. Obtain and keep file of the laundry records.

.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 internal thermometer needed inside the refrigerator in east pantry room.

.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. - Observe the facility without diarrhea and vomiting written procedure/supplies. EHS emailed the poster at the time of inspection.

Observed cracked tile on floor in environmental room (east). Observed floor in the restroom in need of repair in room 204. **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 wall damage in room 106. Observed touch up paint needed on baseboards leading to laundry room. Continue to touch up paint throughout facility. Observed splatters on walls in restrooms in room 104 **.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 dead insects in the light shield in the restroom in room 204. Needs to be cleaned. **.1310 (b) Light fixtures, fans, conduits, and heating, ventilation, and air conditioning vents shall be kept clean and in good repair.

Observed broken vent in room 106, 204 and 224. **.1311 (b) Ventilation equipment shall be kept clean and in good repair.

Observed toilet in need of cleaning in room 106, 104, bathing suite (east), 126, and 204. Observed shower beds in need of cleaning in bathing suites (east and west) and observed shower bed torn in bathing suite (west). Observed handwashing sink in need of cleaning in the laundry room. **.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 bedside commode in need of cleaning in room 204. **.1312 (c) Bedpans, bedside commodes, urinals, shared diaper changing surfaces, and emesis basins that have been used by a resident shall be kept clean and shall be disinfected before use by other residents. Observed disposable urinals not labeled throughout the facility. **.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 medication room missing paper towels. Needs to be provided. **.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices.

Observed no back up water supply plan on hand during the inspection. **.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 rusted drinking fountain in physical therapy. **.1314 (a) Drinking fountains shall be kept clean and in good repair.

Observed wheelchair arms torn in the physical therapy. Staff informed me that the chairs are not currently being used and would be repaired. Observed torn pillow in room 104. **.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.