THE HAVEN IN HIGHLAND CREEK

.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 seats in multiple resident rooms throughout building. Tighten. Observed caulking needed around toilet in resident room on Wilmington hallway. 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 dust and debris on flooring in rooms and restrooms corners, along side wall behind beds/ furniture, underneath the beds throughout 3 communities. Detail cleaning needed. Keep flooring clean throughout. Observed damaged flooring in laundry room in need of repairing. Keep all flooring throughout in good 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 damaged toilet seat in a small spa room of Wilmington. Replacement needed, keep all toilet seats in good repair. Observed damaged toilet tank in restrooms back service hallways. Repair or replacement needed. Observed loose toilet seat in Charlotte 305, 202, 208, 213 in need of repair. Observed soiled shower chair in Charlotte Spa, soiled toilet and sink in Charlotte 316, slow drainage at sink in Charlotte 316. Cleaning and repair needed. Observed hand sink in restroom back service hallway needs caulking. Keep all toilets/hand sinks clean and in good repair. Half point deducted due to improvements.

.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 the facility without vomiting and diarrhea written plan and cleaning up kit. EHS provide the V & D written plan poster at the time of inspection. The facility shall obtain a kit and have it available for such an event at anytime.

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 soiled and/or dusty flooring in room, restroom and underneath the bed throughout 3 communities, not limited to these room (202, 204, 214, 213, 211, 208, 301, 403, 407). Detail cleaning needed and keep flooring clean.

General Comment: .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 mismatch paint from patching holes on the wall. Paint touching up needed.

REPEAT .1311 (b) Ventilation equipment shall be kept clean and in good repair.- Observed bathroom dust on ceiling vent, dust inside AC vents in hallway/common hall. Detail cleaning needed. Keep clean all ventilation clean and good 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 stained/ soiled toilets and hand sinks throughout the communities, not limited to these following. Asheville 202, 204, 214, 211, 208. Charlotte 301, 305, 309, 313. Wilmington 407, 412, 403 (also stained on toilet seat). Observed damaged toilet seat in a small spa room, need replacement. Observed loose toilet seat and hand sink in restroom hallway new caulking needed. Observed soiled toilet/shower chair in a bigger spa room in need of cleaning after each use and between residents. Detail cleaning needed all throughout the bathroom facilities and keep clean. Repair/replace/clean and keep clean.

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 old mattresses and piles of leaves inside the dumpster gate. Cleaning and removing solid waste from the area. Keep area clean.

.1317 (a) Pests shall not be present in an institution's building or buildings.- Observed dead roach on the floor in one of the spa room. Keep all pests away.

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 minor dust and debris on floor behind washer/dryer machines in laundry room floor. Observed debris, dusts underneath the bed, in room and or restroom, area hard to reach behind furniture and corners throughout the facility (Asheville, charlotte, 307, 209 211, 216). Detail and better floor cleaning needed and keep clean. Point remain the same at this time. Note: The cleaning schedule says twice a week. Not exactly indicating what day of the week is actual cleaning day.

.1311 (b) Ventilation equipment shall be kept clean and in good repair.- Observed bathroom ceiling vent in Wilmington 401, and ceiling vent in laundry room need detail cleaning. 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 stained wall around/above hand sink, stained toilet, soiled hand sink in Asheville 211. Soiled toilets and hand sinks in Asheville 216, 209, 202, charlotte 304, 310, Wilmington 401, 409. Two out of four disrepair shower heads and damaged toilet seat in Spa restroom (Asheville). Observed soiled hand washing sinks in common/serving area throughout the facility. Detail cleaning needed all throughout the bathroom facilities and keep clean. Repair/replace/clean and keep clean.

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 dust and debris on floor behind washer/dryer machines in laundry room floor. Observed debris, dusts on flooring underneath the bed, where is hard to reach and corners throughout the facility (316, 201, 211). Detail floor and wall cleaning needed and keep clean. Observed damaged floor in room 211, repair/replace needed.

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, needs repair in 312. Stained wall around hand sink, stained toilet, need better cleaning in 211. Two disrepair shower head and damaged toilet seat in Spa restroom (Asheville), repair or replace needed. Observed soiled hand washing sink throughout the facility, need detail cleaning and keep clean. Hand sink in staff restroom (Wilmington Hall way) start to separate from the wall, need repair or new caulking. Points remain the same at this time.

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 throughout the building (Asheville, Charlotte, Wilmington) measured 119F- 122F. The facility mentioned that they had an issue with water heater and had a replacement recently. Ensure to provide Tempered water between 105F and 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 backup supply written plan. The facility will work on and obtain a complete written plan and have available when needed.

.1317 (a) Pests shall not be present in an institution's building or buildings.- Observed spiders and spider webs along wall and floor throughout rooms especially in 211. Detail cleaning needed and Keep free from pests.

.1318 (a) Food, utensils, medications, and equipment used on medication carts shall be kept clean.- Observed throughout the facility, single use cups face down and store directly on the top medicine cart surface without any protection to prevent contamination. Store all clean items in the manner to keep clean and prevent any possible contamination at all time.

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 debris under sofas/couches, dust in/on surfaces inside the cabinets in the common areas. Need details cleaning and keep clean. Point remains the same at this time.

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 laundry floor need details cleaning around and behind the machines. Keep clean.

.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 toilet seat in Wilmington spa room, need replace. Observed clogged/very slow drainage of hand sink in Charlotte room 314, and general sinks in the main hall. Observed one disrepair hair shampooing basin in the salon, and the other one is leaking. Need repair.

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 water temperature throughout the building measured between 82F- 103F. The facility is working on the issue and will have a contractor coming out soon to address the issues.

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 with an incomplete water backup supply written plan. EHS emailed the director of maintenance a backup water supply plan checklist via email at the time of inspection. The facility will work on and obtain a complete written plan for next inspection.

.1314 (a) Drinking fountains shall be kept clean and in good repair. - Observed water fountains need details cleaning all around spouts, nozzles, and surfaces. Keep clean from hard water buildup and residues.

.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 sofas/couches, dust in/on surfaces inside the cabinets in the common areas. Need details cleaning and keep clean.

General Comment: .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 the facility without diarrhea and vomitus written plan and supplies. EHS provided a hard copy and email the plan to maintenance director at the time of inspection. Education provided.

.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. Scuffs and worn areas on door frames throughout neighborhoods in need of minor touch-up painting.

NO POINTS DEDUCTED .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 plan in place / available, education provided.