SHERWOOD HEALTH & REHAB

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 floors in housekeeping closet in need of cleaning.

.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 in the hallways and cafeteria. Observed scuffed walls and doors throughout the facility. Needs repair. REPEAT.

.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed dust build up in A/C vents in 104 and 100. Need 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 shower bed, shower chair, and toilet in west side spa room in need of cleaning. Observed hopper in east side soiled utility room in need of cleaning. Observed toilet tank lid missing in staff bathroom. REPEAT.

.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed storage in PT bathroom. Bathrooms shall not be used for storage.

.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 in 156 at 101F, in 152 at 98F, in west side spa room at 75F, in east side spa room at 68F, in 106 at 103F, in 157 at 120F, in 104 at 102F and in 100 at 97F. 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 torn pillows cases in 121 and 132. Observed rusty scale in Spa room east. Observed damaged footboard on bed in 149. Observed cabinet door broken in laundry room. Observed table bed in physical therapy room torn.

.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 touch up paint needed to walling and doors in rooms sporadically throughout building. Observed damaged ceiling on building containing back up water supply. Observed some stained ceiling tiles in cafeteria and hallways. 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 shower chair with some build up, tear on shower bed, and loose drain cover in east shower room. Observed tape on shower chair in west shower room. 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 water temperature at 118F -120F throughout. Needs to be 105-116F. 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 thermometer in east wing supply room refrigerator reading 50F. Log stated the temperature was read as 46F earlier this morning. Observed temperature in west nourishment room refrigerator reading 48F. Temperature log had refrigerator in temperature at 5:45 am. Needs to be 41F or below and TCS foods are discarded.

.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/stained ceiling tiles in hallway. Observed minor touch up paint needed to walling and doors in rooms sporadically throughout building. Observed damaged ceiling on building containing back up water supply. 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 chair in 130 in need of cleaning. Observed toilet seat in 138 heavily worn. Observed shower chairs and bed in need of cleaning or repair of fraying in Shower room 2. Observed toilet in need of cleaning and caulking at the bottom in 156.

.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed chairs and other furniture/items not used for toileting/bathing stored in shared spa 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 between 118-120F in multiple rooms. 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 facility does not have complete back up water supply plan. EHS emailed template to facility to fill out.

.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 tears in therapy mat. Needs repair.

.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed build up in refrigerator and microwave in nourishment room. Needs cleaning. 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 tile near main entrance and in laundry room. EHS advises facility to ensure no active leak is occurring and to have stained ceiling tiles replaced. Observed minor touch up paint needed to walling in rooms sporadically throughout building.

.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed wheel chair and other furniture/items not used for toileting/bathing stored in shared spa room located near room 130. REPEAT.

.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 1 urinal not labeled in room 132. -General comment.

.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices. Observed no disposable towels at handsink in laundry room. Paper towels were supplied to handsink during time of inspection. -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 required range in the following areas; room 116-122F, room 146, 91F,

.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 several pallets stacked outside of dumpster area enclosure area. -General comment.

.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed cleaning needed to microwave in nourishment room located on lower 100 hallway. Clean.

.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 tile near main entrance/exit to 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 loose toilet seat in room 106.

.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed bag of linen stored on washing mat in shared spa room located near 100 wing.

.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 drape separator stained in room 132.

.1319 (b) A resident's bed linens shall be changed when no longer clean. Observed staining on residents pillow case located closet to window in room 112.

.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 no documentation on-site for notated rule. EHS advises facility to request a copy of maintenance report when servicer comes to check laundry units to be in compliance with notated rule.

.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 procedure plan for notated rule. EHS emailed director required procedure plan.

.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 throughout facility to include near room 138 and nurses station on east wing. EHS advises facility to ensure no active leak is occurring and to have stained ceiling tiles replaced. Observed walling in need of repair by toilet in room 146. REPEAT IMPROVEMENTS MADE.

.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 141.

.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 reused urinals not labeled in rooms 141 and 146.

.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 ranging between 97F-100F in resident rooms throughout facility. Facility is aware of issue and have ordered a part to fix water heater.

.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. EHS emailed administrator template procedure for require rule. 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 plastic pillow cover torn in room 146. Observed general cleaning needed to outside of refrigerator located in west wing nourishment room. Observed cabinet in need of repair in west wing nourishment room. REPEAT.

.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 staff, drinking water for pitchers is obtained from west wing nourishment room hand washing sink. EHS educated facility that the sink in the room is a handwashing sink only. Drinking water should be obtained from kitchen, bottled water, or water fountains.

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 rusted floors in laundry room area. Observed broken tiles near fire exit door. **REPEAT** EHS advises facility to replace broken/cracked tile as needed within facility.

.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 ceilings and ceilings in need of repair throughout facility. Observed paint touch ups needed in room 137 and in bathroom in room 105. **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. **REPEAT**

.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 open door on garbage can and open lid on recycling bin.

.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 several mattresses stored on outside premises near shed. Per conversation with staff items are scheduled to be picked up.

.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 cabinet in west nourishment room in need of repair. **REPEAT**

.1319 (b) A resident's bed linens shall be changed when no longer clean. Observed staining on linens in rooms 100, 119, 135, 137, and 159. **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 not able to provide vomit and diarrhea procedures nor clean-up kit.