98/ 100
CHARLOTTE HEALTH AND REHABILITATION CENTER
1735 TODDVILLE RD, Charlotte, NC 28214
Rest/Nursing Homes · NC permit/State ID 2060400010
Latest result98 / 100
Last inspectedJun 25, 2026
Inspections on record26
On record sinceSep 20, 2013
Score history
Sep 20, 2013Higher is betterJun 25, 2026
Inspections & violations
Jun 25, 2026 98 / 100 · 1 violation
#2 · Walls and ceilings clean, good repair −2
Observed touch up paint needed behind some headboards during the inspection
**.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair.
Dec 31, 2025 96 / 100 · 4 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −2
Observed floor tile in need of repair in the restroom adjacent to room 208 and in the nourishment room on 200 hall.
**.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.
#2 · Walls and ceilings clean, good repair −1
Observed touch up paint needed in soiled utility room on 200 hall, restroom in 208, room 214, room 118 and the soiled room on 100 hall. Observed ceiling peeling in the spa on 100 hall.
**.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair.
#5 · Ventilation equipment clean, good repair
Observed vent cover with dust build up in the restroom next to room 208.
**.1311 (b) Ventilation equipment shall be kept clean and in good repair.
#7 · Facilities provided, accessible, clean, good repair −1
Observed shower bed torn in the spa on 100 hall.
**.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.
Feb 19, 2025 93.5 / 100 · 5 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −2
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 floor in 100 hall. Observed. Floor next to tub in 100 bathing room in need of cleaning. Observed floors in 102 room and bathroom in need of cleaning. Observed floors in need of cleaning in 112 and 117 bathroom. Observed damaged floor in dining room. REPEAT.
#2 · Walls and ceilings clean, good repair −2
.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 window sills in 110 and 117. Observed damaged wall in 100 hall. Observed chips and scuffs on walls throughout. Needs repair. REPEAT.
#7 · Facilities provided, accessible, clean, good repair −1
.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 shower curtain in 100 bathing room. Observed shower bed in both 100 and 200 bathing rooms with torn Matt’s. Observed worn toilet seat in 110. Observed cracks on toilet chair in 217. Needs repair.
#12 · Bathing facilities properly equipped, equipment cleaned and disinfected −1.5
.1312 (f) Bathing equipment that has contact with a resident's skin and is used by more than one resident shall be kept clean and shall be disinfected between resident uses. Equipment located within a bathing facility that uses a pump to move water shall be kept clean in accordance with the manufacturer's instructions. Observed 100 hall bathing room tub in need of cleaning. Needs cleaning. REPEAT. Points not escalated due to difference between violation item on last inspection compared to this inspection.
#30 · Medication carts clean; sharps containers attached; food, utensils, medication and medication dispensers properly handled
General Comment:
.1318 (a) Food, utensils, medications, and equipment used on medication carts shall be kept clean. Observed over stacked single-use cups on medication carts. Needs to be stored to protect cups to maintain cleanliness.
Aug 19, 2024 93.5 / 100 · 5 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −2
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 flooring in bathrooms and resident rooms having damaged floor and/or peeing floor tiles in need of repair.
#2 · Walls and ceilings clean, good repair −2
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 walls scuffed in resident rooms throughout in need of repair / touch-up painting.
#5 · Ventilation equipment clean, good repair −0.5
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed PTAC units having dirty filters in need of general cleaning.
#12 · Bathing facilities properly equipped, equipment cleaned and disinfected −1.5
.1312 (f) Bathing equipment that has contact with a resident's skin and is used by more than one resident shall be kept clean and shall be disinfected between resident uses. Equipment located within a bathing facility that uses a pump to move water shall be kept clean in accordance with the manufacturer's instructions. Observed spa’s used without disinfectant used for disinfecting. CDI disinfectant provided
#33 · Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled −0.5
.1319 (b) Bed linens that are provided by the institution for use by residents shall be free from holes and tears. Observed linen having holes and tears in need of replacing inside resident room #204.
Apr 22, 2024 90 / 100 · 9 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −2
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 flooring in dining room. Observed glue on floor in 126 bathroom. Observed bathroom floors need cleaning in 111 and 104. Observed damaged tile in 100 hall. REPEAT.
#2 · Walls and ceilings clean, good repair −2
.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 broken tile on wall in 200 bathroom. Observed paint peeling in 200 housekeeping, in 200 activity, bathroom of 203 and bathroom 212. Observed paint chipping in several doorways throughout. Observed damaged window sill in 126. REPEAT.
#7 · Facilities provided, accessible, clean, good repair −2
.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 floor needing cleaning in 100 shower. Observed toilet needing cleaning in room 111 and room 229. Observed toilet seat peeling in PT bathroom. Observed toilet chair rusting in 200 shower and in room 212. Observed hair washing sink nozzle in need of cleaning in salon. Needs cleaning/ repair. REPEAT.
#12 · Bathing facilities properly equipped, equipment cleaned and disinfected −1.5
.1312 (f) Bathing equipment that has contact with a resident's skin and is used by more than one resident shall be kept clean and shall be disinfected between resident uses. Equipment located within a bathing facility that uses a pump to move water shall be kept clean in accordance with the manufacturer's instructions. Observed shower chair in shower rooms 200 and 100 with build up under seats. Observed shower beds with torn mats that are in need of cleaning in both shower rooms. Observed tubs in both shower rooms in need of cleaning.
#20 · Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair
.1314 (c) Ice machines, buckets, and scoops shall be kept clean and in good repair. Observed build up in ice machines in both nourishment rooms. Needs cleaning.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair −0.5
.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 water damage to cabinets under sink in Nourishment room 100. Observed torn mat table, trampoline cover, and chair on hand pedal equipment in PT room. Observed damaged counter top in salon. Observed bed laminate peeling in 229 and 126. REPEAT.
#38 · Food service equipment and utensils clean, good repair
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed build up in refrigerators in nourishment stations and activity kitchens. Observed build up in microwave in Nourishment 200. Needs cleaning.
#44 · Time/Temperature Control for Safety (TCS) foods maintained as required −2
.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 liquid food served with medicine that requires refrigeration after opening on med carts at 53F. Drink is kept in ice in coolers. Ice had melted and was not filled enough to maintain temperature. Needs to be kept at required temperatures.
#45 · Hot and cold holding equipment provided; thermometers provided, accurate
.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 not thermometer in physical therapy room fridge and in 100 hall activity room fridge. Needs thermometer.
Oct 26, 2023 94 / 100 · 5 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −2
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 floor in 100 hall bath shower with debris. Observed build up on floors behind toilet in room 103, 204, and 110. Observed stained carpet in 224 and 229. Observed dust and debris build up in house keeping, linen, and other storage closets. REPEAT.
#2 · Walls and ceilings clean, good repair −2
.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 window sill damaged in 103 and 110. Observed ceiling stain in central supply closet. Observed ceiling stain in 100 hall. Observed scuffs and small wall damage throughout facility. Observed water damage on wall under vanity in room 122. Needs repair. REPEAT
#7 · Facilities provided, accessible, clean, good repair −2
.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 seats loose in 103 and 125. Observed shower floor cracking and shower head cracked in 122. Observed liquid spill in shower room 100 tub and debris in shower room 200 tub. REPEAT.
#18 · Drinking fountains clean, good repair
.1314 (a) Drinking fountains shall be kept clean and in good repair. Observed build up on water fountains. Needs cleaning. REPEAT.
Points not escalated due to water fountain being repaired and is motion sensor with no handle.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair
.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 tear in cushion for wheel chair in 100 hall bathing room. Observed build up and water damage under vanity in beauty shop sink. Observed tears in beauty shop chair.
May 11, 2023 95.5 / 100 · 9 violations
Inspector comments: NOTE: Observed missing a drain plug in one the dumpsters, need a replacement of drain plug.
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −1
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 severely water stain/damaged on floor tiles in bathroom 200, little minor here and there throughout the facility floor. PIC stated there was water damaged because of bursted pipes when cold weather hit last winter.
#2 · Walls and ceilings clean, good repair −1
.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 stain on ceiling in some rooms, conference room, 100 hallway. PIC stated it was not an active leak. It was old stain from previous management. Need repair and paint touch up and keep in good repair. Observed damaged wall where a soap dispenser fell off in 200 hallway bath, wall possibly cut or scratched from wheelchair in bathroom 123. Observed one room in 100 hallway, missing a based board on bottom floor. Need repair and keep in good repair.
#5 · Ventilation equipment clean, good repair
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed dusts on the air conditioner filter in residents room. Need cleaning and keep clean.
#7 · Facilities provided, accessible, clean, good repair −1
.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 most of the rooms throughout the facility. Observed loose faucet handle in some room. Need repair and keep in good repair. Observed some toilets throughout the facility with pink/black line in toilet bowl, Need cleaning and keep clean.
#16 · Hot water between 105°F and 116°F −1.5
.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 throughout the facility range from 117F-120F. PIC stated they just changed a system about two days ago. PIC will call the company to come out and adjust the water temperature to be between 105F and 116F to prevent burning hazard. VERIFICATION NEEDED ON 5/16/2023.
#18 · Drinking fountains clean, good repair
.1314 (a) Drinking fountains shall be kept clean and in good repair. Observed broken on around handle on water fountain in 100 hallway. Need repair or replace
#20 · Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair
.1314 (c) Ice machines, buckets, and scoops shall be kept clean and in good repair. Observed mildew on wall,ceiling, splash guard in the ice machine in 200 hallway. Need cleaning and keep clean.
#51 · Proper use of restriction, exclusion, and reporting
.1324 (c) Institution employees shall comply with the requirements for exclusion from work and restriction due to communicable disease or illness required for food employees as set forth in Parts 2-201.12 and 2-201.13 of the Food Code incorporated by reference at 15A NCAC 18A .2650 as amended by 15A NCAC 18A .2652. NEW RULES. No point deduction. Discuss the topic with staff and provided Employee Health Policy poster at the time of inspection.
#52 · Vomitus and diarrheal clean up supplies; written clean up procedures available and complete
.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. NEW RULE. No point deduction. Discuss the topic with staff and provided Vomitus and diarrhea poster at the time of inspection, The facility need obtain the actual kits ready for such an event.
Nov 7, 2022 96 / 100 · 3 violations
Inspector comments: NO POINTS DEDUCTED
#6
Ensure no microbial growth is observed; Observed PTAC units collecting excess debris in residents rooms throughout especially inside #210.
#10
Label bed pans and urine collection containers; Observed urine collection container stored hanging from handrail inside shared bathroom between room #108 - #106
#28
Provide adequate storage / storage properly arranged to facilitate cleaning; Observed storage closets / supplies rooms with open supply boxes stored of flooring in need of proper storing
#3 · Walls and ceilings cleanable, clean, good repair −2
REPEAT
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed numerous walls throughout resident rooms scuffed in need of touch-painting / repair.
#14 · Disinfectant accessible, properly used −1
A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). Observed disinfectant not accessible inside spa rooms during inspection; CDI disinfectant provided.
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
REPEAT
All common linen including sheets, pillow cases, absorbent pads, towels, and wash cloths provided by the facility must be sanitized between users with an EPA registered laundry sanitizer or by other methods described in 15A NCAC 18A .1319 (b). Observed no documentation that linen is being sanitized during washing cycle. (Note) points taken at half due to varying violation rule.
Jun 13, 2022 95 / 100 · 4 violations
#2 · Floors clean, carpet clean, dry, odor free −1
Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed carpet inside resident room (#225) stained in need of detailed cleaning.
#3 · Walls and ceilings cleanable, clean, good repair −2
REPEAT
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed walls damaged behind trash cans within facility that have lids that open and come in contact with surfaces of walls; walls in these areas are in need of touch-up painting.
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
REPEAT
All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a). Observed broken cabinet doors inside nourishment room on 200 hall in need of repair.
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
All common linen including sheets, pillow cases, absorbent pads, towels, and wash cloths provided by the facility must be sanitized between users with an EPA registered laundry sanitizer or by other methods described in 15A NCAC 18A .1319 (b). Observed no proof that linen is being disinfected on site; facility washes sheets and linen together on site and will work with company (Eco-Lab) to provide documentation.
Jul 14, 2021 93 / 100 · 4 violations
Inspector comments: NO POINTS DEDUCTED
#30. Miscellaneous. 15A NCAC 18A .1318
Observed pill crusher on med cart with buildup. Maintain cleanliness of pill crushers to avoid contamination.
#5. Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). Observed a/c unit filters in rooms 126 and 115 in need of cleaning. Observed bath hall 100 ventilation in need of cleaning. Maintain all ventilation and filters clean.
#3 · Walls and ceilings cleanable, clean, good repair −2
Keep all walls, floors, and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed activity room wall with markings. Keep walls clean. Observed ceiling in hall 214 with stain. Observed hole on floor of wheelchair building storage at the back of facility in need of replacement or repair. Maintain cleanliness and repairs of walls, floors, and ceilings. REPEAT VIOLATION -2-
#8 · Facilities conveniently located, clean and in good repair −2
Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed in bath hall 100 with brown/black stain on bathing pad and shower curtain. Observed in bathing hall 200 tear on bathing pad and brown stain on shower curtain. Replace or clean as/if needed. REPEAT VIOLATION -2-
#13 · Lavatory and bathing hot water between 100 and 116 F −1
Maintain the hot water at all resident accessible handwashing sinks and bathing facilities within the temperature range of 100°F to 116°F. 15A NCAC 18A .1312 (e). Observed hot water temperatures in room 216 at 118F, room 214 at 118F, room 108 at 118F, and room 115 at 117F . Maintain water temperature from 100F - 116F. -1-
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −2
All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a). Observed social parlor in hall 100 chairs with food debris and social parlor in hall 200 with stained pillows. Observed in room 108: blue stains on sheets, room 115: tear on green cover sheet and yellow stain on fitted sheet. Replace and/or maintain cleanliness of furniture as needed. REPEAT VIOLATION -2-
Apr 26, 2021 96 / 100 · 3 violations
Inspector comments: No points deducted: #28--Clean floor tech closet and central supply room. Items on floor. #33--Label all soiled linen bins. Covid 19 restrictions, no signature required. Terry present.
#3 · Walls and ceilings cleanable, clean, good repair −1
Observed cove base needing to be reattached to wall near 102. Observed stained ceiling near activity room, 100 hall and 200 hall. Observed wall damage under sink in 120. Observed hole in wall near mop sink in floor tech room on 100 hall.
#8 · Facilities conveniently located, clean and in good repair −2
Observed rust on toilet chair in rooms 207, 216, 216, and 225. Observed stains on shower chairs on 100 hall shower room. Observed red/black residue/staining on fabric on shower chair in 100 hall shower room.
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed rust on door of refrigerator in activity room, damaged blue chair in day room, stains on separation curtain in room 102, stained air mattress cover in 102, stains on ottoman in 207, torn pillow in 216, and damaged/rotted night stand in 216.
Nov 10, 2020 96.5 / 100 · 4 violations
Inspector comments: NOTE--Residents are confined to their rooms at time. No therapy animals.
#3 · Walls and ceilings cleanable, clean, good repair −1
Observed stains on ceiling in room 130 and in hallways (from leak).
#8 · Facilities conveniently located, clean and in good repair −1
Observed shower floor tiles with black residue(200 hall bathroom). Observed stains on shower curtain in 200 hall bathroom. Obsrved toilet seat stained in room 130.
Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
#9 · Toilet rooms free of storage, hand wash signs posted −0.5
Observed trash stored in 200 hall bathroom.
Toilet rooms shall not be used for storage. See rule .1312 (b).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed damaged window sill in room 213.
All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
Jan 15, 2020 95.5 / 100 · 5 violations
Inspector comments: General Comment: No points deducted: #5
15 NCAC 18A .1311 Lighting, Ventilation, and Moisture Control. Ambient air temperature shall be maintained in the range of 65F to 85F - Observed a ambient air temperature of 86F in room 129
#13 · Lavatory and bathing hot water between 100 and 116 F −1
15 NCAC 18A .1312 Toilet: Handwashing: Laundry: and Bathing Facilities. Facilities shall provide hot water within the temperature range of 100F and 116F at all lavatories and bathing facilities. Observed a water temperature of 117F in room 129
#28 · Adequate storage, area clean, items properly stored −0.5
15 NCAC 18A 1318(a) All patient care consumable items shall be stored at least eight inches above the floor to prevent water contamination. Observed disposable undergarments in open bag stored on floor and a box of tongue depressors that had broken open and was making contact with shelving in storage room and nursing storage of 200 hall.
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
15 NCAC 18A .1318 Medication carts shall be cleaned when visibly soiled. Unused medication cups shall be kept covered or inverted. Observed unused medication cups stored upright on two unattended medication carts in 100 hall. Also observed an unsecured pill/tablet not in a bottle or blister pack.
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
15 NCAC 18A .1319(a) All furniture, mattresses, or other furnishings shall be kept clean and in good repair. Observed food debris on bedside table that had not be cleaned along with debris on mattress that had been recently fitted with sheets and bedding. Observed food underneath cushions in social parlor of 100 hall.
#33 · Linen changed when soiled. Soiled linen handled properly −1
15 NCAC 18A .1319(b) Carts for soiled laundry shall be labeled for soiled laundry use only. Observed unlabeled soiled laundry carts in laundry facility.
15 NCAC 18A .1319(b) Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. Observed bed linens in room 107 with minor staining.
Nov 5, 2019 96 / 100 · 3 violations
Inspector comments: No points deducted: #32--Observed damage to arm of chair stored in hall near shower room and tape residue on chair (blue/green) outside of room on 200 hall.
#3 · Walls and ceilings cleanable, clean, good repair −1
Observed damage to window pane in room 126. Observed ceiling stained on 200 hall.
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#8 · Facilities conveniently located, clean and in good repair −2
Observed staining on shower chairs in 100 hall shower room and stained toilet seats in 123 and 126.
Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Observed build up /debris on pill crushers on med carts. Observed single service cups unprotected and stacked high on one med cart (200 hall). Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).
Unused medication cups shall be kept covered or inverted. 15A NCAC 18A .1318 (c).
Apr 22, 2019 95 / 100 · 4 violations
Inspector comments: No points deducted: #3--Observed wall damage above baseboard in restroom in 119. #36--Observed small amount of black residue on ice chute inside 200 hall nourishment room.
#1 · Floors easy to clean, no obstacles, drains where needed −1
Observed broken/damaged/ bulging floor tiles in 100 hall spa, 119(restroom), and101(restroom).
Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b).
#8 · Facilities conveniently located, clean and in good repair −2
Observed residue around wheel of shower chair in 100 hall spa.
Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
#9 · Toilet rooms free of storage, hand wash signs posted −1
Observed box with window items stored in 200 hall spa.
Toilet rooms shall not be used for storage. See rule .1312 (b).
#33 · Linen changed when soiled. Soiled linen handled properly −1
Observed stained pillow cases, sheets, or torn pillows in rooms 128B, 119, 101, and 213.
Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).
Nov 29, 2018 90 / 100 · 9 violations
Inspector comments: No points deducted: #1-- Observed damaged floor tiles in various rooms on 100 hall. #10--Observed observed urinal unlabeled in room 129 and observed urinal needing to be cleaned in room 200.#16--Locate back up water supply plan. Example given. #23--Observed items stored on full sharps container in both shower rooms. #28--Observed personal items (purses) store in med rooms near meds. #42--Follow instructions on med plus drink. #43--Provide thermometer in small fridge in room 110.
#3 · Walls and ceilings cleanable, clean, good repair −1
Observed wall paint chipped in activities room include backsplash of sink, room 101 including bathroom, room 114, social parlor, 110 bathroom, house keeping closet(100hall), 115, and 225. Repair hand rail near soiled line closet on 100 hall.
#8 · Facilities conveniently located, clean and in good repair −2
Observed observed build up on shower head in spa room 100 hall. Observed shower chair soiled and damaged in 100 hall spa. Observed damaged/soiled shower bed pad in 200 hall spa. Observed toilet tank lid not fitted.
#9 · Toilet rooms free of storage, hand wash signs posted −0.5
Observed non bath related intems stored in both shower rooms (chairs, wheelchair parts, etc.).
#11 · Hand sinks used only for intended purpose −1
Observed utensils stored in activities room sink and in nourishment rooms. Sinks intended for hand washing.
#19 · Ice protected, dispensed, equipment clean in good repair −1
Observed ice bin with build up inside bin, food debris inside ice, and unattended on hall. Observed debris in ice sopp container in nourishment.
#21 · Solid waste stored properly, areas clean, facilities for cleaning −2
Observed trash, debris, and unused equipment around dumpster area. Clean.
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Observed med carts overstacked, needing to be cleaned, pill crushers soiled, inside base of drawers soiled, kleenex stored on sharps container, and personal drinks stored on med cart. Observed med cart unlocked and unattended on 200 hall.
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed separation curtains stained, damaged foot/headboards, blinds, and pillows torn in various rooms throughout. Observed covered table damaged in rehab.
#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −0.5
Observed damaged armrest on geri chair in social parlor and damaged cushion on Nu step equipment in rehab. Observed briefs stored on floor in room 200. Items stored on floor in outside storage room.
Apr 16, 2018 92 / 100 · 6 violations
Inspector comments: NO POINTS DEDUCTED
#8 Lavatories clean and in good repair; Observed room #114 having flooring inside lavatory in need of cleaning.
#32 Patients furniture clean and in good repair; Observed chair inside room #112 soiled in need of cleaning.
#3 · Walls and ceilings cleanable, clean, good repair −1
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed walls in all resident rooms damaged in need
of repair / re-painting.
#21 · Solid waste stored properly, areas clean, facilities for cleaning −2
The rooms, enclosures, designated areas, and containers shall be adequate for the storage of all solid wastes accumulating on the
premises. 15A NCAC 18A .1316 (c). Observed old bed frames and misc equipment stored behind facility in need of proper storage /
disposal.
#28 · Adequate storage, area clean, items properly stored −1
REPEAT
Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a). Observed
clean linen stored underneath drain lines underneath hand washing sink in Hair Salon.
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −2
REPEAT
Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c). Observed drawers on med cart having
loose pills in bottom of drawers; Observed old med packages and debris underneath bottom drawer in need of cleaning.
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
REPEAT
Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean
linen. 15A NCAC 18A .1319 (b). Observed pillows stored on floor in clean linen closet in 200 Hall. (points not increased due to improvement).
#40 · Food brought by employees or visitors handled properly −1
REPEAT
Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's
food supply and shall be labeled with the name of the person to receive the food and the date the food was brought into the facility.
15A NCAC 18A .1321 (b). Observed personal food stored above institution's food in nourishment room on 200 Hall.
Oct 26, 2017 90.5 / 100 · 8 violations
Inspector comments: General Comment:
#3.Continue to touch-up paint throughout in rooms, bathrooms, door framing to rooms and bathrooms. Repair wall in floor maintenance room. Repair lower section of wall in house keeping cart room on 100 hall. Replace damaged floor tile in hallway area on 100 hall and in common sitting room on 100 hall. Clean repaint ceiling around ceiling ventilation on 200 hall and re-wrap duct work if needed. Clean wall in med room on 200 hall. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#9. Highly recommend removing extra shower chairs and toilet chairs from common bath/showers.**Toilet rooms shall not be used for storage. See rule .1312 (b).
#15. Place back flow prevention device on faucet fixture in floor maintenance room.**Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).
#19. Replace damaged ice scoop on ice chest on 100 hall. Ice scoop replaced at time of inspection.**Ice machines, buckets, other containers, and scoops shall be maintained in good repair. 15A NCAC 18A .1314 (b).
#21. General cleaning of grounds behind dumpster area and provide drain plug for dumpster---> no vermin issue observed.**All solid wastes containing food scraps or other decomposable materials shall, prior to disposal, be kept in leak-proof, non-absorbent containers, which shall be kept covered with tight fitting lids when filled or stored, or not in continual use. 15A NCAC 18A .1316 (a).
#23. Observed no sharps container in common bath/shower on 100 hall sharp dispenser holder and old razors stored on top of sharp container holder. Sharps container provide in sharps dispenser holder at time of inspection.**All medical waste shall be handled and disposed of as required in 15A NCAC 13B .1200 Medical Waste Management.
#26.Cut tree growth back from roof and gutter of facility to prevent any roof leaks. Repair facia board/gutter on back side of facility. Observed gutter and facia board pulling away from side of roofing.**There shall be no fly or mosquito breeding places, rodent harborages, or undrained areas on the premises. 15A NCAC 18A .1317 (c).
#8 · Facilities conveniently located, clean and in good repair −1
Replace damaged shower pad on shower bed in 100 hall common bath. Clean spa tub in 100 hall and keep clean even if not being used. Thoroughly clean underside of shower pad in 200 hall common bath. Provide correct toilet tank lid for toilet in resident bathroom. Tighten loose toilet seats in resident bathroom. Tighten handle on hand washing sink faucet fixture in 110 bathroom. Repair or replace counter top back splash in activity kitchen.
Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
#14 · Disinfectant accessible, properly used −2
Provide disinfectant in common shower at all time so shower fixture can be cleaned and disinfected between uses! Observed disinfectant solution missing from 100 common shower/bath.
A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).
#28 · Adequate storage, area clean, items properly stored −1
NO STORAGE UNDER HAND WASHING SINKS. Observed storage under hand washing sink med room. Observed box of gloves stored on shower bed in 100 hall common bath. Clean shelving and base of drawers where single service articles are stored in nourishment room. Remove case of supplies off the floor in out side storage room. Observed extra equipment stored behind facility(chairs and bed). Store items in a storage shed or remove extra equipment from premises.
Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a).
All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −2
Observed employee drink and food stored in drawers with medicine on med cart. Do not store or place personal drinks or food in drawers of med cart. Clean base drawers of med carts. Observed several loose pills in base of med cart. Observed single service articles not properly stored on and in med cart. Minimize the amount of single service article cups stored on side of med carts. Do not store multiple cups on top of med carts. Do not store storage bags on top of sharp container on med cart.
Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).
Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c).
Unused medication cups shall be kept covered or inverted. 15A NCAC 18A .1318 (c).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Continue to refurbish or replace damaged foot boards on bed. Tighten loose pulls/handles on drawer and closet doors. Replace damaged pillow in resident room. Clean spot on curtains separating resident bed. Replace damaged arm rest on wheel chair. Thoroughly clean tape from foot boards of beds. Thoroughly clean side railing on beds. Repair or replace damaged padding on PT table and equipment. All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
#33 · Linen changed when soiled. Soiled linen handled properly −1
Keep lid on soiled linen bin in soiled utility room! Observed lids missing from over soiled linen bins and lids stored in and on hand washing sinks. Label soiled linen bin in PT room and laundry room area.
Soiled linen shall be placed in a covered container or bag at the point of use and stored and handled so as to contain and minimize aerosolization of and exposure to any waste products. 15A NCAC 18A .1319 (b).
Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b).
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
Observed bag of clean linen stored on the floor in resident room. Do not store or place bags of clean linen on the floor!
Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. 15A NCAC 18A .1319 (b).
#40 · Food brought by employees or visitors handled properly −0.5
Observed food not properly labeled and stored in nourishment area refrigeration units. Label food brought into facility with resident/employee name and date food was brought into facility. Store food brought into facility below and away from food products provided by facility.
Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply and shall be labeled with the name of the person to receive the food and the date the food was brought into the facility. 15A NCAC 18A .1321 (b).
Mar 9, 2017 92.5 / 100 · 7 violations
Inspector comments: #2 - Observed tiles missing near the wall in the TV room. Observed damage in therapy room kitchen area on the kick plates below the stove.
#3 - Observed cleaning needed in the grout on the wall to the right of the hand sink in the 100 hall bathing room. Continue to touch-up paint on walls and door frames throughout facility where needed.
#12 - Observed batteries needed in the paper towel dispensers in the med room by the therapy room and in the 200 hall bathing room.
#19 - Observed minor cleaning needed in the ice machine in the 200 hall nourishment room.
#21 - Observed missing drain plug in back dumpster and a crack in the front dumpster. Replace drain plug and front dumpster. Observed cleaning needed in area surrounding dumpsters.
#29 - Observed drainage pipe leading into the parking lot with debris coming out. Maintenance stated that floor tech was disposing of wax water down the drain right next to the outdoor mop sink. Ensure all mop water is being disposed of properly using the mop sink drain.
#34 - Observed chemicals being stored on the top shelf in the clean linen closet on the 100 hallway. Ensure clean linen is properly stored without risk of contamination. Provide proof of maintenance and testing of proper disinfection of linen.
*Observed full sharps container in the 100 hall bathing room. Empty sharps container when full.
Inspection led by Savannah Parker and observed by Shawn Blackmon.
#5 · Ambient air temperature 65 to 85 F, equipment clean −1
Observed cleaning needed in the air filters of the AC units in the activity room, and room 210. Observed debris in vents in room 101 and 208.
**Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).
#8 · Facilities conveniently located, clean and in good repair −1
Observed cleaning needed under shower chair in100 and 200 hall bathing rooms. Observed build-up on the bottom of the toilet chair in room 120. Observed toilet seat unattached from toilet in 200 hall bathing room. Observed leak in the pipe under the sink in the activity room. Observed a leak in the hand sink faucet in room 210.
**Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
**Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
**Keep all hand washing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
#14 · Disinfectant accessible, properly used −2
Observed no disinfectant present in the 200 hall bathing room and shampoo instead of disinfectant hooked up to the disinfectant tube of the spa tub.
**A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).
#28 · Adequate storage, area clean, items properly stored −0.5
Observed single service cups being stored on the floor in the central supply room. Observed cup dispenser in nourishment room uncovered. Keep cups covered to prevent contamination.
**All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
**Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Observed build-up on the pill crusher on the med cart in the 100 hallway and a personal drink being stored in the bottom drawer on top of medicine. Observed clean gloves being stored directly on top of sharps container on the med cart on 100 hall way.
**Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed a stain on the mattress in room 137. Observed tears in therapy beds in the therapy room. Observed build-up on the bottoms of bed trays in rooms 101 and 122. Observed cleaning needed on curtain separators in room 109 and 122.
**All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
**Mattresses shall be kept clean, dry, and odor free. 15A NCAC 18A .1319 (a).
#33 · Linen changed when soiled. Soiled linen handled properly −1
Observed stains on pillow and on sheets in room 109. Observed soiled sheets on the bed near the door in room 101, in room 224 and observed soiled blanket and sheets on the bed near the door in room 120. Observed an odor in the soiled utility hold closet on the 200 hallway due to soiled linen container being uncovered.
**Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).
**Soiled linen shall be placed in a covered container or bag at the point of use and stored and handled so as to contain and minimize aerosolization of and exposure to any waste products. 15A NCAC 18A .1319 (b).
Nov 2, 2016 95.5 / 100 · 5 violations
Inspector comments: General Comment:
#5. Observed some debris under top of heating and cooling unit in room 101. Observed some slight dust accumulation on vent covers and return air covers in hallway area. Clean area under cover on heating and cooling units. Wipe/dust ceiling return air vent covers and ventilation covers.*** Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).
#12. Observed soap missing from soap dispenser in bio hazard room on 100 hall. Soap placed in dispenser at time of inspection. Keep soap and paper towels at all hand washing sinks at all times.*** Provide liquid soap and disposable towels at all hand washing sinks. 15A NCAC 18A .1312 (d).
#21. Replace missing drain plug on trash dumpster.***** All solid wastes containing food scraps or other decomposable materials shall, prior to disposal, be kept in leak-proof, non-absorbent containers, which shall be kept covered with tight fitting lids when filled or stored, or not in continual use. 15A NCAC 18A .1316 (a).
#32. Touch-up foot boards on beds and hand washing sink cabinet which varnish/sealant has worn off and exposing bare wood surfaces.**32. All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
Mr. Nickolas Kanitz and Ms. Karla Gunnon present at time of inspection.
#3 · Walls and ceilings cleanable, clean, good repair −1
Tightly secure loose rubber cove base molding in bio hazard room on 100 hall. Repair wall and base board in bathroom connecting room 133 with adjoining room. Touch-up paint walls and door framing throughout in rooms and bathrooms where needed. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −1
Observed several urinals and basin for bedside commodes not properly labeled. Label items with residents name and date. Label the basin and item itself and not the bag. Observed marking coming off of several bags that urinals were stored in. Recommend labeling labeling basin with name and not 200A and 200B.
Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).
#14 · Disinfectant accessible, properly used −1
Provide disinfectant spray in common bath/showers at all times. Today only disinfectant wipes provided in bathroom on 100 hall. Provide approved disinfectant in spray bottles so shower walls, floor, shower beds, etc can be spray down and disinfected.
A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).
#28 · Adequate storage, area clean, items properly stored −1
Observed med cups and single service cups(styrofaom) not properly stored in closet on 100 hall and social parlor on 100 hall. Observed single service articles lid not properly stored/covered in nourishment room/closet. Store cases of single service articles off the floor in storage room. Do not store styrofoam cups loosely and sitting on table in social parlor. Observed several bagged items stored on the floor in closet on 200 hall. Store items on shelving.
All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −0.5
Replace cut mattress in room 133. Discard and replace damaged pillow in room 101. Observed briefs stored on the floor in room 101. Do not store or place briefs on the floor. Store briefs on shelving or on top of closet cabinet in room. Discard and replace any linen with holes present. Observed small hole on fitted sheet on resident bed in room 101. General Comment: Provide documentation from laundry vending service where clothes washer machine is being serviced and providing a chlorine reading when tested.
Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).
Mar 28, 2016 94 / 100 · 5 violations
Inspector comments: General Comment: #3. Continue to touch-up paint throughout where needed.***Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. #5. Clean top cover on heating and cooling unit in activity room and 1 room on 100 hall.**Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). #5. Observed disinfectant solution missing from cabinet in common bath/shower on 200 hall. Provide properly mixed disinfectant in common shower/bath cabinet at all times. Container of disinfectant provided in bathroom immediately at time of inspection.**A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). #32. Continue to touch-up foot board on beds and night stands in residents room.***All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a). Mr. Thomas McNeil and Mr. Nicholas present at time of inspection.
#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −1
Observed bed pans and urinals not labeled throughout in residents room and bathrooms on 100 and 200 hall. Label bed pans and urinals with resident name and date. Observed urinal stored in bathroom with a strong smell from not being properly clean. Properly clean urinals in bio hazard room or replace. Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c). All bedpans/urinals/emesis basins shall be cleaned after each use. 15A NCAC 18A .1312 (c). REPEAT!
#23 · Medical wastes handled and disposed of properly −1
Observed sharps container in both 100 and 200 hall common shower/bath overflowing/ completely full. Empty sharps container often/regular in bathroom/common shower!
All medical waste shall be handled and disposed of as required in 15A NCAC 13B .1200 Medical Waste Management.
#28 · Adequate storage, area clean, items properly stored −1
Observed pillows stored in wheel chair in common bath/shower on 100 hall. Observed box of gloves stored on shower bed in common bath/shower on 100 hall. Do not store or place pillows in shower area. Do not store or place gloves on shower beds in bathrooms. Observed sleeving of plastic lids and styrofoam cups stored under hand washing sink in nourishment room on 200 hall. NO STORAGE UNDER HAND WASHING SINKS! Continue to clean and organize storage under desk and in closet in activity room. Recommend storing items in plastic bin in activity room. Observed oxygen tanks not properly stored in resident room and tank storage room. Store oxygen tanks in a holder. Observed storage on the floor in central supply room/closet. Observed single service articles cup dispenser not covered in nourishment room. Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a). All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a). REPEAT!
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −2
Observed single service articles not properly stored on med carts. Observed plastic cups not inverted down, cup over filled in baskets, cups laying on top of carts, hand sanitizer stored in basket with single service articles. Observed base of drawers on med cart soiled. Observed employee jacket stored in drawer on cart with medicine and single service articles. Observed single service articles stored in card board box on med cart on 200 hall.
Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c). Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c). Unused medication cups shall be kept covered or inverted. 15A NCAC 18A .1318 (c). REPEAT!
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
Observed clean linen carts on 100 hall not covered. Keep linen carts covered! Observed linen on therapy table and pillow. Keep a sheet over clean linen on therapy table and pillows or do not put linen on therapy table and pillow until ready to be used. Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. 15A NCAC 18A .1319 (b).
Sep 24, 2015 91.5 / 100 · 9 violations
Inspector comments: General Comment: #8. Replace faucet fixture on hand washing sink in room 211 and 227. Faucet fixtures are pitting. Either tightly secure loose laminate on cabinet in 200 common shower/bath or replace wall mounted cabinet.**Keep all hand washing facilities clean and in good repair. 15A NCAC 18A .1312 (b). #21. Observed small hole in base of trash dumpster. Replace trash dumpster.** Mr. Thomas McNeil and Mr. Nicholas Kanitz present at time of inspection.
#1 · Floors easy to clean, no obstacles, drains where needed −1
Observed damaged floor tiles around floor drain in 200 hall common bath/shower. Observed missing grout between floor tiles in 200 hall common bath/shower. Observed damaged and missing floor tiles in 100 hallway social parlor. Observed cracked/damaged floor tiles in 200 hallway. Replace damaged floor tiles in shower and hallway area. Regrout floor in bath/shower area. Replace damaged and missing floor tiles around base of floor in social parlor. Clean floor under desk area in activity room. Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b). Floors shall be free of obstacles to cleaning. 15A NCAC 18A .1309 (a).
#3 · Walls and ceilings cleanable, clean, good repair −1
Touch-up paint/repaint throughout in resident rooms, bathrooms, door framing and storage closet. Observed water stain on ceiling in room 109 ,126 and 214. Monitor ceiling for any roof leaks and repair if needed. Clean wall in 121 bathroom. Repair wall behind bed in room 101. Repair wall beside/behind ice machine in nourishment room located on the 100 hall.Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#5 · Ambient air temperature 65 to 85 F, equipment clean −1
Observed ceiling ventilation in hallway dusty. Observed top covers on heat and cooling units throughout in some room soiled and debris under top covers. Clean ceiling ventilation and cover on heating and cooling units within rooms. Clean area under top covers on units.Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).
#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −1
Observed bed pans and urinals not labeled throughout in residents room and bathrooms. Label bed pans and urinals with residents name and date.Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).
#19 · Ice protected, dispensed, equipment clean in good repair −1
Observed ice machine soiled on the 200 hall. Observed ice scoop holder soiled in nourishment center on both 100 and 200 hall.. Observed microbial growth present in base of ice scoop holder. Thoroughly clean interior of ice machine and ice scoop holder.Ice machines, buckets, other containers, and scoops shall be cleaned on a regular schedule such that they are kept free of scum, rust, mold or other contamination. 15A NCAC 18A .1314 (b).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Observed base of drawers on med carts soiled. Observed single service articles not properly stored on med carts and in nourishment centers. Observed med cup, water cups and pill crusher stored in cardboard box. Observed single service articles stored with scissors, alcohol pad and suppository. Store single service articles inverted down and covered. Do not store alcohol wipe, scissors and suppository with or near single service articles. Do not store single service articles in cardboard box. Store single service articles in a plastic zip loc bag or plastic container. Store single service articles in nourishment center in plastic sleeving. Do not store or place single service articles under plumbing fixture in med room on 100 hall. Thoroughly clean pill crushers on 100 hall. Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c). Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c). Unused medication cups shall be kept covered or inverted. 15A NCAC 18A .1318 (c).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Repaint or restain head board and foot boards on beds. Observed stain worn and coming off of head and foot boards throughout in residents rooms. Tightly secure television shelving in room 109. Replace missing handles on closet doors in residents rooms. Thoroughly clean chairs in resident room and social parlors or replace if stains does not come off of chair covering. Replace damaged padding on physical therapy table. Do not attempt to tape over damaged area. Tape adhesive can serve as a medium for bacteria growth. Repair damaged arm rest and seat in wheel chair All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
Observed clean linen and pillow stored on shower bed in common shower on 100 hall. Do not store or place clean linen in common shower/bath. Do not store clean linen on shower bed! Store clean linen in clean linen closet or in resident room.
#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −0.5
Observed three boxes of gloves stored on shower bed in common bath/shower on 100 hall. Observed spray can of air freshener stored with wound care items in wound care med cart. DO NOT STORE OR PLACE GLOVES ON SHOWER BED! DO NOT STORE HAZARDOUS PRODUCTS WITH WOUND CARE ITEMS!Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).
Feb 4, 2015 92.5 / 100 · 9 violations
Inspector comments: 2: Observed: Outside central supply closet flooring dirty/collecting trash/debris. **Keep all flooring clean. 3: Observed: Minor wall damaged. The ceiling collecting dust in the Lobby. **Keep all walls and ceilings clean and in good repair.17: Observed: Lobby water fountain mouthpiece broken and dirty. **Keep all water fountains clean in good repair.19: Observed: Ice chest with interior damaged in the 200 hall Nourishment Room. **Keep all equipment clean and in good repair.33: Observed: Two new soiled linen bins in rehab without labels. **Label all soiled linen bins as such.David Olmstead and Thomas McNeal present.
#1 · Floors easy to clean, no obstacles, drains where needed −1
Observed: Several areas of flooring, at direct exit doors, with broken tiles. Broken shower floor tile in the 100 hall Spa.Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b).
#5 · Ambient air temperature 65 to 85 F, equipment clean −1
Observed: Most AC unit filters dirty, in rooms inspected.Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).
#8 · Facilities conveniently located, clean and in good repair −1
Observed.: A damaged shower pad and a loose toilet base and toilet seat in the 100 hall Spa. A dirty toilet seat in 102. A damaged sink faucet in the 100 hall Soiled Utility room. A loose toilet seat in the 200 hall Spa.Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).Keep all hand washing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −0.5
Observed: Bed pans not properly labeled in 214 and 223. Urinals dirty in 214. Bedside commode dirty in the shower stall in the 200 hall Spa.Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).All bedpans/urinals/emesis basins shall be cleaned after each use. 15A NCAC 18A .1312 (c).All bedside commodes shall be cleaned after each use. 15A NCAC 18A .1312 (c).
#14 · Disinfectant accessible, properly used −1
Observed.: No disinfectant available for the whirlpools. No spray disinfectant in the 200 hall Spa.A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).
#26 · Premises clean, no breeding places or rodent harborage −1
Observed: Excessive amounts of old mattresses and equipment around facility.There shall be no fly or mosquito breeding places, rodent harborages, or un-drained areas on the premises. 15A NCAC 18A .1317 (c).
#28 · Adequate storage, area clean, items properly stored −0.5
Observed.: Patient care related items on the floor in Outside Central Supply, within 8" in the 200 hall Supply Closet, and a box of socks on the floor in 200 hall linen closet.All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed: Most beds with damaged head/foot boards. Interior/exterior of night stands with damaged. Lobby sofa collecting debris beneath cushions. Salon drawers dirty. Cabinet dirty in 200 hall nourishment.All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, Venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
#40 · Food brought by employees or visitors handled properly −0.5
Observed: Patient food in Nourishment fridges without dates.Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply and shall be labeled with the name of the person to receive the food and the date the food was brought into the facility. 15A NCAC 18A .1321 (b).
Sep 19, 2014 94 / 100 · 6 violations
Inspector comments: General Comment: #22. Discard and remove old trash can lids from premises. Observed trash can lids collecting water behind facility.**All solid wastes shall be disposed of with sufficient frequency and in such a manner as to prevent insect breeding or public health nuisances. 15A NCAC 18A .1316 (d). #30. Clean cracks and crevices on pill crusher. Observed old build up in crack and crevices on pill crusher. The area where pills are crushed was clean.**Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c). #12. Observed no paper towels at hand sink in bio hazard room. Paper towels were provided at hand sink at time of inspection and paper towel dispenser was repalced at hand sink at time of write up of inspection. **Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). Mr. Thomas McNeil and David Olmstead present at time of inspection.
#3 · Walls and ceilings cleanable, clean, good repair −1
Observed wall damaged behind head board on residents bed. Repair wall behind resident head board throughout facility where needed. Reattach loose rubber cove base moulding under heating and cooling unit in room 110. Observed microbial growth on lower section of wall under heating and cooling unit in room 101. Address any leaks that may be causing wall damage under heating and cooling unit and repair and repaint wall. Touch-up paint throughout facility where needed; if needed.Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. All walls shall be easily cleanable. 15A NCAC 18A .1310.
#8 · Facilities conveniently located, clean and in good repair −1
Observed pitted faucet fixture on hand sink in room 119 and 104, floor tile missing around shower drain in common bath on 100 hall and lower section of shower wall missing tiles in common bath on 200 hall. Replace pitted faucet fixture on hand sink in room 119, 104 and monitor other faucet fixtures on hand sink throughout facility and replace if needed. Shower wand in room 119 cleaned at time of inspection.
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed torn/damaged chair and stain on chair in lobby area, damaged over bed tables, foot board on bed and night stands with exposed pressed board/wood, stains on chairs in resident room and damaged drawers on storage closet in residents room. Replace torn chairs in lobby area. Clean stains from chairs or replace chairs. Replace damaged over bed tables. Apply varnish/stain to exposed pressed board/wood on furniture/fixture and repair drawers on storage closets in resident room.All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −0.5
Observed cushion/arm rest on jerry chairs damaged and damaged padding on physical therapy table. Repair or replace damaged jerry chair and padding on PT table.Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).
#36 · Approved utensils and equipment, cleaned and sanitized −2
Observed plastic cups with moisture between cup stored in cabinet area of activity kitchen. After talking with activity director she informed me that cups were clean at sink in activity kitchen. The only sink in activity kitchen is a hand washing sink. Utensil washing of cups and other utensils could be done in activity kitchen if kitchen had a two compartment sink and separate hand washing sink.All multi-service utensils shall be washed, rinsed and sanitized between each user using a method listed in 15A NCAC 18A .2619.Activity kitchens or nutrition stations that are not approved to clean food service utensils and equipment shall return all food service utensils, equipment, and utensils not continuously subjected to high temperatures to the kitchen after each use to be washed, rinsed, and sanitized. 15A NCAC 18A .1320 (b).
#40 · Food brought by employees or visitors handled properly −0.5
Observed food products stored in activity refrigeration with no name or date. Label food products with resident/staff name and date. Any food made in activity kitchen need to be used and discarded the same day. Activity kitchen is limited to 12 residents or less. Food kept in refrigeration unit after activity made be used by another resident in facility that is not part of the original 12 participating in that activity.Food brought from home by employees or visitors of patients or residents shall be kept only as long as it is clean, and free from spoilage. 15A NCAC 18A .1321 (b).Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply and shall be labeled with the name of the person to receive the food and the date the food was brought into the facility. 15A NCAC 18A .1321 (b).
Jan 22, 2014 93 / 100 · 7 violations
Inspector comments: 3: Wall damage in the Lobby Restroom. Window sill damage in 109. Damaged wall in 100 Hall Housekeeping. Ceiling damage in House Laundry.Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.21: Some trash and leaves collecting in dumpster area. Solid waste containers, rooms, or designated areas shall be kept clean. 15A NCAC 18A .1316 (c).30: Single service spoons on a med cart with the handles down. Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c).32: Damaged chair in Social Parlor.All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).40: Staff fridge not labeled as such in Activity. Label "staff". Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply and shall be labeled with the name of the person to receive the food and the date the food was brought into the facility. 15A NCAC 18A .1321 (b).42: Food sitting out at room temp in the 100 Hall Nourishment Room. Food was removed from Kitchen at 8:30. Food shall be served or discarded by 10:30. Potentially hazardous foods served shall be either consumed or discarded within two hours of being removed from temperature control. 15A NCAC 18A .1323 (a)Provide documentation that the Whirlpool Disinfectant is EPA registered as a Hospital Grade Disinfectant. Linda Mechling present.
#5 · Ambient air temperature 65 to 85 F, equipment clean −1
Observed: Dirty AC slats in 109, 108, and 210. Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).
#8 · Facilities conveniently located, clean and in good repair −1
Repeat: Observed: A dirty toilet seat in 109 and 108. A damaged sink stopper in 108. Dirty bathing equipment in the 200 Hall shower room. Broken sink fixture in the 200 Hall shower room. Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Keep all hand washing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −0.5
Observed: Urinals not cleaned after use in 231. The urinal cleaned in the resident sink in 231. All bedpans/urinals/emesis basins shall be cleaned after each use. 15A NCAC 18A .1312 (c).Where facilities for cleaning bedpands/urinals are not provided in patient rooms, bedpans shall be taken to a soiled utility room and be cleaned and disinfected using an EPA registered hospital disinfectant after each use. 15A NCAC 18A .1312 (c).
#14 · Disinfectant accessible, properly used −1
Observed: No disinfectant in the 200 Hall shower room. A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).
#15 · Approved water supply, no cross-connections −2
Repeat: Observed: No backflow prevention devices on the 100 Hall mop sink hose bib (left) and on the shower wands in Shower Rooms. Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).
#28 · Adequate storage, area clean, items properly stored −0.5
Observed: Patient care items within 8" of the floor in Outside Supply, 200 Hall Supply, and 100 Hall Supply. Food below the sink in Activity. Single service cups not protected in the Dining Hall. Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a).All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a).
#36 · Approved utensils and equipment, cleaned and sanitized −1
Observed: The microwave with splatter in the 100 Hall Nourishment room. The interior of the freezer dirty and the interior of the cooler dirty in the 200 Hall Nourishment room. Non-food contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. See rule .1320 (c).
Sep 20, 2013 96 / 100 · 4 violations
Inspector comments: 15- General Comment: Observed shower wands and the tub wands without back flow prevention.Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).32- General Comment: Observed a dresser missing a handle in 108 and 133. Hole in comforter in 108. All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).Mr. Henry Devito present during inspection.
#8 · Facilities conveniently located, clean and in good repair −1
Observed toilet chair with rust and chipping paint in 216. A Loose toilet seat in rehab. Shower chair collecting pink residue in 200 hall. Tile damage on the shower floor in 100 hall. (repeat non-compliance)Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
#19 · Ice protected, dispensed, equipment clean in good repair −1
Observed ice cooler left unattended in 100 hallway. Ice machine collecting pink residue in 100 and 200 hall. Ice machines, buckets, other containers, and scoops shall be protected from the elements, splash, drip, dust, vermin, other contamination, and from use by unauthorized personnel. 15A NCAC 18A .1314 (b). Ice machines, buckets, other containers, and scoops shall be maintained in good repair. 15A NCAC 18A .1314 (b).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Observed single-service cups not properly protected on all most med carts inspected. Single-service spoons stored in splash zone in 100 Med Room. Pill crushers collecting dust and debris.Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c).
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
Observed linen stored below the hand sink in the Beauty Salon. (repeat non-compliance)Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. 15A NCAC 18A .1319 (b).
Source: Mecklenburg County Public Health – Environmental Health public inspection portal (search for “CHARLOTTE HEALTH AND REHABILITATION CENTER” or State ID 2060400010). Inspection type (routine vs. follow-up) is not published in the county's data.