Observation: The shared restroom with assisted bath - Tub observed unclean. Evaluate cleaning procedures for this tub as per manufacturer instructions. Maintain all fixtures clean and in good repair.
15A NCAC 18A .1312 TOILET: HANDWASHING: AND BATHING FACILITIES
(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.
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Observation: The following rooms had water temperatures not within range of the required 105F - 116F: Rm 110, Rm 222 (Unoccupied), Room 201 (Unoccupied). 15A NCAC 18A .1313 WATER SUPPLY
(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
Room 310 (111F); Room 307 (114F); Room 303 (109F); Room 317 (108F); Room 110 (102F); Room 112 (116F); Room 120 (114F); Room 217 (112F); Room 218 (114F); Room 213 (111F); Room 201 (102F); Room 205 (109F); Room 222 (118F)
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General Comment: The backup water plan does not contain language details as noted in .1313:
(e) The administrator shall immediately notify the licensing agency and the local health department that serves the
county in which the institution is located if the institution`s primary water supply is interrupted for more than four
consecutive hours. 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 back up 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.
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Observation: Ice being provided (self-service) in the cafe area to residents without protected dispensing. Observed small cooler with ice scoop stored on counter. Cooler was removed from service counter for access.
15A NCAC 18A .1314 DRINKING WATER FACILITIES: ICE HANDLING
(c) Ice shall be protected against physical, chemical, and biological contamination and shall be kept clean. Ice
machines, buckets, and scoops shall be kept clean and in good repair. 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.
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General Comment: Ensure that residents and staff are directed to take reusable dishware from the activity kitchens to the main dietary kitchen to wash, rinse and sanitize. Reusable dinnerware, glassware observed in kitchen cabinets. A 2 compartment sink OR a dishwasher is not available in these kitchen areas.
15A NCAC 18A .1320 ACTIVITY KITCHENS, REHABILITATION KITCHENS, AND NOURISHMENT
STATIONS
(a) All food service equipment and utensils shall be kept clean and in good repair. Institutions shall be allowed to use
domestic food service equipment in activity kitchens, rehabilitation kitchens, and nourishment stations.
(b) Utensils that have been used to prepare, serve, or consume food or drink shall be returned to the dietary kitchen
and shall be washed, rinsed, and sanitized. Notwithstanding the foregoing sentence, utensils may be washed, rinsed
and sanitized at activity kitchens, rehabilitation kitchens, and nourishment stations that are equipped with the
following:
(1) a two compartment sink with 24 inch drainboards or counter top space at each end of the sink for
handling used utensils and air drying clean and sanitized utensils. The sinks shall be of sufficient
size to submerge, wash, rinse and sanitize utensils; or
(2) a dishwashing machine approved by National Sanitation Foundation International
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The air temperature of the refrigerator in the 2nd Floor Activity kitchen was measured at 54F. There were no temperature control food products being stored in this refrigerator. There is not an ambient air thermometer being used in the refrigerator. ***REPEAT***
15A NCAC 18A .1323 FOOD PROTECTION IN ACTIVITY KITCHENS, REHABILITATION
KITCHENS, AND NOURISHMENT STATIONS
(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. Time as a public health control may be used as specified in Section .2600 of this
Subchapter, except that written procedures shall not be required.
(b) Hot and cold holding equipment shall be used to maintain required temperatures for TCS food. Each refrigeration
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General Comments
Please maintain an updated copy of RULES GOVERNING THE SANITATION OF HOSPITALS, NURSING HOMES, ADULT CARE HOMES, AND OTHER INSTITUTIONS 15A NCAC 18A .1300 https://ehs.dph.ncdhhs.gov/oswp/docs/rules/1300Rulebook.pdf
Observed window screens missing from Sitting Room, Rm 319 Please remove grease receptacle from soil area and store on asphalt/concrete area at rear kitchen door.
.1323- Noted ambient air thermometer missing for the refrigerator located in the 2nd Activity Kitchen. Hot and cold holding equipment shall be used to maintain 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.
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Noted hot water reaching up to 123 F for the 2nd floor Assisted Bathing room. Also noted hot water spikes up between 117-118 F in guest room 218. Also noted hot water for the 3rd floor guest rooms only reaching up to 75 F. Noted guest rooms were vacant and not in use. 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.
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General Comments
Observed some light stains on the carpet near the main living room area.
.1312 Lavatory and bathing hot water shall be between 100F-116F. Observed on the second floor the shared bathroom hand sink reached a temp of 130F and in room 112 the bathroom sink reached 82F.
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Facility has a back up supply plan. However, the supply plan will need a water source that is not a local store and for potable water to have a source for showering and dish washing. Also, include the agreement with local pool facilities for providing water for toilet flushing.
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Provide documentation that the commingled laundry is being sanitized with a minimum of 50ppm chlorine or the equivalent.
.1312; No paper towels at the hand sink in the beauty salon. Provide paper towels at hand sinks.
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.1312; Water temperature 128F at the hand sink in the shared bathroom on the 2nd floor. Water temperature at the hand sink is 138F in the beauty saloon. Lavatory and bathing hot water shall be between 100F-116F.
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General Comments
Due to COVID 19, Please follow CDC guidelines regarding social distancing, quarantine, and disinfecting. REHS discussed formula recall with Patty Ostapowicz, the director.
