HomeMy WebLinkAboutHeritage Care 400005 04 30 10.jh.pdf
Health Department Community On-Site System Current Facility ID Capacity Old Facility ID Name Change Verification of Closure Status Change Inspection Re-inspection Visit Water Community
Transient Non-Community Non-Transient Non-Community Non-Public Water Supply DRINKINGWATERFACILITIES,ICEHANDLING: [.1314] 17. Water fountains clean, good repair, properly regulated ...
18. Drinking utensils properly handled .................................. 19. Ice protected, dispensed, equipment clean, in good repair FURNISHINGS AND PATIENT CONTACT ITEMS: [.1319,.1312]
32. Furniture clean and in good repair. Mattresses clean, dry, odor free ........................................................................... 33. Linen changed when soiled. Soiled
linen handled properly 34. Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately. ........................... 35. Patient contact items in
good repair, properly stored, cleaned and disinfected ................................................................. FLOORS, WALLS AND CEILINGS: [.1309, .1310] 1. Floors easy to clean,
no obstacles, drains where needed . 2. Floors clean, carpet clean, dry, odor free .......................... 3. Walls and ceilings cleanable, clean, good repair .............. LIGHTING,VENTILATION,MO
ISTURECONTROL: [.1311] 4. Lighting at least 10 foot candles 30 inches above floor .... 5. Ambient air temperature 65° to 85° F, equipment clean ...... 6. No evidence of microbial growth
........................................ 7. Indoor smoking limited to dedicated smoking rooms ....... TOILET, HANDWASHING, LAUNDRY AND BATHING FACILITIES: [.1312] 8. Facilities conveniently
located, clean and in good repair . 9. Toilet rooms free of storage, handwash signs posted ...... 10. Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected
...................................... 11. Hand sinks used only for intended purpose .................... 12. Lavatories have mixing faucet or tempered water, soap, hand towel or hand
drying device ............................................. 13. Lavatory and bathing hot water between 100° and 116° F 14. Disinfectant accessible, properly used ...............................
WATER SUPPLY: [.1313] 15. Approved water supply, no cross-connections ............... 16. Quantity and hot water sufficient, backup water supply plan LIQUID AND SOLID WASTES [.1315,
.1316] 20. Wastewater disposed of properly .................................... 21. Solid waste stored properly, areas clean, facilities for cleaning .................................................
........................... 22. Solid waste disposed of frequently, no insect breeding or nuisance ........................................................................... 23. Medical
wastes handled and disposed of properly .......... VERMIN CONTROL, PREMISES: [.1317] 24. Vermin excluded ................................................................ 25. Approved
pesticides properly stored and handled .......... 26. Premises clean, no breeding places or rodent harborage .. 27. Pet areas clean, veterinary records available ....................
MISCELLANEOUS: [.1318] 28. Adequate storage, area clean, items properly stored ....... 29. Mop sinks provided and used ......................................... 30. Medication carts
clean, sharps containers affixed, food and utensils handled properly ................................................ 31. Feeding syringes and oral suction catheters handled properly,
tube-feeding bags changed per instructions .... FOOD SERVICE UTENSILS AND EQUIPMENT: [.1320] 36. Approved utensils and equipment, cleaned and sanitized 37. Activity kitchens used only
for approved activities ........ 38. Handwash lavatory provided wherever food is handled . FOOD SUPPLIES AND PROTECTION: [.1321, .1322, .1323] 39. Food supply complies with 15A NCAC
18A .2600 ........... 40. Food brought by employees or visitors handled properly ...... 41. Milk and milk products comply with 15A NCAC 18A .1200 42. Food protected. Potentially hazardous
food maintained at 45°F or below, or 140°F or above, consumed or discarded within 2 hours of being removed from temperature control ........... 43. Food storage units with thermometers,
maintain temperatures 44. Food stored above floor .................................................... 45. No live animals where food is prepared or stored. Pets prevented from contaminating
food utensils, equipment, condiments, pets excluded and tables cleaned before meals ....... EMPLOYEES: [.1324] 46. Clothing clean, no tobacco used while handling food ..... 47. Hands
properly washed or decontaminated ..................... 48. Persons with infections excluded from food service work N.C. Department of Environment and Natural Resources Division of Environmental
Health Wastewater System: Water sample taken today? State: NC Status Code: City: Zip: City: State: Zip: Location Address: Name of Establishment: Mailing Addr. INSTRUCTIONS: Purpose:
General Statute 130A-235 requires the Commission for Health Services to adopt rules governing the sanitation of institutions. 15A NCAC 18A .1304 specifies the contents of an inspection
form to record the results of inspections made of institutional facilities. This form is developed to be used in making inspections of orphanages, children's homes, and similar institutions.
Preparation: Local environmental health specialists shall complete the form every time they conduct an inspection. Prepare an original and two copies for: 1. Original to be left with
the administrator or manager. 2. Copy for the local health department. 3. Copy for the Environmental Health Services Section, Division of Environmental Health. Disposition: This form
may be destroyed in accordance with Standard-8.B.6., Inspection Records, of the Records Retention and Disposition Schedule for County/District Health Departments which is published by
the North Carolina Division of Archives and History. Additional forms may be ordered from: Division of Environmental Health, 1632 Mail Service Center, Raleigh, NC 27699-1632, (Courier
52-01-00) DENR1213 (Revised 7/05) Environmental Health Services Section (Review 7/08) Inspection of Hospitals, Nursing Homes, Adult Care Homes and Other Institutions Inspection by: EHS
I.D. # TOTAL Permittee: Deductions Full/Half (circle one) Deductions Full/Half (circle one) Rept Received by: Date of Insp/Chg: Score 2 1 2 1 2 1 2 1 3 1.5 2 1 2 1 1 .5 1 .5 2 1 3 1.5
2 1 2 1 4 2 2 1 2 1 2 1 2 1 4 2 4 2 2 1 2 1 3 1.5 2 1 2 1 1 .5 1 .5 2 1 2 1 2 1 2 1 2 1 1 .5 2 1 2 1 2 1 1 .5 2 1 4 2 1 .5 2 1 4 2 1 .5 1 .5 2 1 1 .5 3 1.5 2 1 12 34 1 2 Additional Comment
Sheet Attached 12V Yes No Yes No //18 2018400005 93.5 0 4 3 0 1 0 A 0 HERITAGE CARE PIERCE MANAGEMENT GROUP 3430 LESTER ST CONOVER 28613 PO BOX 129 CONOVER 6.5 1654
N.C. Department of Environment and Natural Resourses Division of Environmental Health COMMENT ADDENDUM Time In: Time Out: Total Time: City: Street: ID: Name: : am pm : am pm HERITAGE
CARE 2018400005 3430 LESTER ST CONOVER 1 2 1 0 816 24 32 42 tile grout in showers on men's hallway stained hot water to be maintained from 100-116 deg f--129-133 on women's hallway flies
present replace worn furniture hot hold.all heated foods above 135 deg f--bbq sandwiches reheated to 165
N.C. Department of Environment and Natural Resourses Division of Environmental Health COMMENT ADDENDUM City: Street: ID: Name: HERITAGE CARE 2018400005 3430 LESTER ST CONOVER
N.C. Department of Environment and Natural Resourses Division of Environmental Health COMMENT ADDENDUM City: Street: ID: Name: HERITAGE CARE 2018400005 3430 LESTER ST CONOVER
N.C. Department of Environment and Natural Resourses Division of Environmental Health COMMENT ADDENDUM City: Street: ID: Name: General Comments: HERITAGE CARE 2018400005 3430 LESTER
ST CONOVER