97.5/ 100
ROCKWELL PARK REHABILITATION AND HEALTHCARE CENTER
1930 W SUGAR CREEK RD, Charlotte, NC 28213
Rest/Nursing Homes · NC permit/State ID 2060400034
Latest result97.5 / 100
Last inspectedMay 28, 2026
Inspections on record26
On record sinceSep 20, 2013
Score history
Sep 20, 2013Higher is betterMay 28, 2026
Inspections & violations
May 28, 2026 97.5 / 100 · 8 violations
Inspector comments: *NOTE: Director, Shonda Wingate, was present during time of inspection. Report emailed to:
Swingate@rockwellparkrehab.com
#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 minor damage to walling/touch up paint needed to walling throughout building. Observed popcorn ceiling with brown staining near entrance to dining room.
#5 · Ventilation equipment clean, good repair −0.5
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed ceiling throughout facility with dust accumulation. Clean.
#9 · Bedpans, urinals, bedside commodes and emesis basins properly cleaned and disinfected
.1312 (c) When disposable bedpans, emesis basins, and urinals are reused, they shall be labeled so that they are associated with an individual resident. Observed reusable urinal not labeled in room 148. -General comment.
#16 · Hot water between 105°F and 116°F
.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 reach 133F in room 182. All other areas checked during time of inspection hot water was in required range. -General comment.
#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 vinyl pillow torn in room 166. Pillow as thrown away and replaced by administrator during time of inspection. -General comment.
#33 · Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled
.1319 (b) A resident's bed linens shall be changed when no longer clean. Observed crumbs on bed linen in room 148. -General comment.
#38 · Food service equipment and utensils clean, good repair −0.5
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed shelving and flooring of refrigerator in need of cleaning located on west wing.
#43 · Food brought into the institution by employees or visitors of patients or residents properly stored, labeled and dated −0.5
.1321 (b) Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply as described in rule .1321 (a). Such food shall be labeled with the name of the resident or employee that the food belongs to and the date the food was brought into the institution. Labeling as required by this Rule shall not be required for food items stored in employee-designated or individual residents' refrigerators or rooms. Observed outside food not properly labeled stored in west wing nourishment refrigerator.
Nov 21, 2025 97.5 / 100 · 7 violations
#2 · Walls and ceilings clean, good repair
.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 hole behind entry door to room 180. -General comment.
#5 · Ventilation equipment clean, good repair −0.5
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed minor dusting needed to ceiling vents throughout facility.
#8 · Toilet rooms free of storage, handwash signs posted −0.5
.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed pillows stored on shower bed in shared spa room located on north-south wing.
#16 · Hot water between 105°F and 116°F
.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 reach 130F in room 180. All other water temperatures checked during time of inspection were within required range. -General comment.
#20 · Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair −1
.1314 (c) Ice shall be protected against physical, chemical, and biological contamination and shall be kept clean. Observed ice chest stored unlocked and unattended on West unit.
#26 · Premises properly maintained
.1316 (d) An institution's exterior premises, including parking lots, lawns, and walkways, and interior premises within the institution's building or buildings, shall be kept free of garbage, solid waste, yard trash, and pest harborages. Observed dilapidated furniture stored outside of storage shed within facilities premises. -General comment.
#38 · Food service equipment and utensils clean, good repair −0.5
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed rusting to inside of microwave stored in nourishment room on West unit.
Jun 20, 2025 96.5 / 100 · 7 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −1
Observed floor tile in the laundry room in need of repair. New maintenance director informed that the replacement tiles were on site and would begin being replaced today. Observed strong urine smell in the bathroom in room 243. Cleaning staff had not been on that hall yet.
**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
Observed wall in need of repair behind the washing machine in the laundry room.
**.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 filter in need of repair in room 299.
**.1311 (b) Ventilation equipment shall be kept clean and in good repair.
#7 · Facilities provided, accessible, clean, good repair −1
Observed toilet seat in need of repair in Hampton Spa. Observed tub in need of cleaning in rooms 299 and 280. Observed toilet chair in need of cleaning in room 243. Observed grout in the shower in Southend Spa in need of cleaning.
**.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair.
#12 · Bathing facilities properly equipped, equipment cleaned and disinfected −1.5
Observed shower bed torn in the South Hampton and West Lake spa.
**.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.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair
Observed cabinet in need of repair in the laundry room.
**.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.
#33 · Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled
Observed small hole in the linen on the bed in room 299.
**.1319 (b) Bed linens that are provided by the institution for use by residents shall be free from holes and tears.
Nov 13, 2024 96 / 100 · 4 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −2
Observed floor tread peeling in the restroom in room 272 and 241. Observed floor in need of cleaning in the restroom in room 241. Observed floor tile missing in the laundry room.
**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 bathroom wall in need of repair in the restroom in room 272, 242 and in the soiled room on west hall. Improvement.
**.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair.
#7 · Facilities provided, accessible, clean, good repair −1
Observed toilet chair loose and stained in room 242 and 241.
**.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.
#9 · Bedpans, urinals, bedside commodes and emesis basins properly cleaned and disinfected
Observed urinal not labeled in room 272.
**.1312 (c) When disposable bedpans, emesis basins, and urinals are reused, they shall be labeled so that they are associated with an individual resident.
Jun 26, 2024 96 / 100 · 6 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −1
Observed floor tile in need of repair in the laundry room and soiled utility (west) closet.
**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 wall damage in room 299 and soiled utility (west) room. Observed ceiling peeling on 200 hall and in laundry room.
**.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 filter broken in room 299.
**.1311 (b) Ventilation equipment shall be kept clean and in good repair.
#7 · Facilities provided, accessible, clean, good repair −1
Observed rusted toilet chair in room 299. Removed during the inspection. Observed shower bed cushion torn in spa (North Point and South Bend)
**.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.
#8 · Toilet rooms free of storage, handwash signs posted −1
Observed wheel chairs stored in the spas (South Bend and West Lake).
**.1312 (b) Bathrooms shall not be used for storage of items not currently in use.
#38 · Food service equipment and utensils clean, good repair
Observed microwave rusted in the nourishment room. Microwave was removed and replaced.
**.1320 (a) All food service equipment and utensils shall be kept clean and in good repair.
Dec 19, 2023 95.5 / 100 · 7 violations
#2 · Walls and ceilings clean, good repair −1
Observed ceiling in need of repair/painting near room 281, ceiling near the spa (south) and west hallway. Observed wall damage in laundry room.
**.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair.
#8 · Toilet rooms free of storage, handwash signs posted −0.5
Observed wheel chair stored in the spa (west). Chair was removed during the inspection.
**.1312 (b) Bathrooms shall not be used for storage of items not currently in use.
#12 · Bathing facilities properly equipped, equipment cleaned and disinfected
Observed shower bed torn in the spa (south). Bed was removed during the inspection.
**.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.
#16 · Hot water between 105°F and 116°F −1.5
Observed water reach 96F in the spa (south), 130F in room 180, 128F in room 179 and 125F in room 176. Water temperature went down to 115F after running for awhile.
**.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.
#17 · Back-up water supply plan available and complete
Observed incomplete back-up water supply plan on site during the inspection. REPEAT VIOLATION.
**.1313 (e) The institution shall have a written plan to obtain a backup water supply in the event that the institution's primary water supply is interrupted for more than four consecutive hours. The written plan shall identify a backup water supply or alternate source of water that provides two liters of potable water per day per resident and institution employee for drinking and potable water for food preparation, hand washing, bathing, cleaning, dishwashing, laundry, and disposal of bodily waste. This may include a plan for relocating residents to a facility with a water supply that satisfies Paragraph (a) of this Rule. If an institution's primary water supply or backup water supply becomes unsafe for human consumption, then the water sources within the institution, such as sink faucets, shall be labeled or hooded to prevent their use, and the administrator shall provide potable water for use by the institution's residents and employees.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair
Observed staining on curtain in room 176. Needs to be cleaned.
**.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.
#34 · Linens provided by the institution properly cleaned and sanitized −1.5
Observed no documentation on site stating what the ppm of sanitizer dispensing into washers. Establishment commingles linens. Have service provided provide documentation on that the ppm of sanitizer is being dispensed. REPEAT VIOLATION.
**.1319 (c) Linens provided by the institution that are not clean shall be cleaned and sanitized in accordance with this paragraph. When hot water in washing machines is used to sanitize linens provided by the institution, the washing machines shall be operated in accordance with the manufacturer's instructions. When chemicals are used to sanitize linens provided by the institution, linens shall be washed in accordance with the following:
(1) using a solution of at least 50 parts per million chlorine; or
(2) using laundry sanitizer that is registered in accordance with 40 C.F.R. 152 and that is used in accordance with the manufacturer's instructions.
Apr 20, 2023 95.5 / 100 · 10 violations
Inspector comments: *NOTE: Anglecia Askew was present during time of inspection along with Head of Maintenance. Kernard Dingle. Report emailed to Director at the following: Sebastian.adams@choice-health.net
#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 carpet staining throughout facility.
#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 toilet heavily soiled in room 123. Observed black build up inside the shower tiles in “south spa” room.
#8 · Toilet rooms free of storage, handwash signs posted −0.5
.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed storage in shared spas to include wheels chairs and pillows (west spa and south spa).
#9 · Bedpans, urinals, bedside commodes and emesis basins properly cleaned and disinfected −0.5
.1312 (c) When disposable bedpans, emesis basins, and urinals are reused, they shall be labeled so that they are associated with an individual resident. Observed reusable urinals throughout facility not labeled with individual residents name.
#16 · Hot water between 105°F and 116°F
.1313 (d) Institutions shall provide water heating facilities. Hot and cold running water under pressure shall be provided to carry out all operations. Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities. Observed water not within required range in the following areas; room 119 at 97F, room 123 at 98F.
#17 · Back-up water supply plan available and complete −0.5
.1313 (e) The institution shall have a written plan to obtain a backup water supply in the event that the institution's primary water supply is interrupted for more than four consecutive hours. The written plan shall identify a backup water supply or alternate source of water that provides two liters of potable water per day per resident and institution employee for drinking and potable water for food preparation, hand washing, bathing, cleaning, dishwashing, laundry, and disposal of bodily waste. This may include a plan for relocating residents to a facility with a water supply that satisfies Paragraph (a) of this Rule. If an institution's primary water supply or backup water supply becomes unsafe for human consumption, then the water sources within the institution, such as sink faucets, shall be labeled or hooded to prevent their use, and the administrator shall provide potable water for use by the institution's residents and employees. Observed incomplete backup water supply plan.
#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 white pillows torn in rooms throughout facility (168, 175, 278).
#34 · Linens provided by the institution properly cleaned and sanitized
.1319 (c) Linens provided by the institution that are not clean shall be cleaned and sanitized in accordance with this paragraph. When hot water in washing machines is used to sanitize linens provided by the institution, the washing machines shall be operated in accordance with the manufacturer's instructions. When chemicals are used to sanitize linens provided by the institution, linens shall be washed in accordance with the following:
(1) using a solution of at least 50 parts per million chlorine; or
(2) using laundry sanitizer that is registered in accordance with 40 C.F.R. 152 and that is used in accordance with the manufacturer's instructions.
Observed no documentation detailing the required 50ppm chlorine usage in system for linen provided by the institution.
#38 · Food service equipment and utensils clean, good repair −0.5
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed cleaning needed to shelving in refrigerator in nourishment room on West wing. Observed detailed cleaning needed to microwave in nourishment room on West wing.
#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. Observed no written plan or kit to clean a vomitus or diarrheal incident. EHS emailed facility a procedure plan.
Nov 10, 2022 94 / 100 · 5 violations
Inspector comments: NO POINTS FOR THE FOLLOWING VIOLATIONS:
#2. Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed minor carpet staining throughout facility. Carpet was in the process of being cleaned during time of inspection. Major improvement has been made to flooring throughout facility.
#3. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed several patches of popcorn ceiling in need of repair throughout facility. Observed touch up paint needed in residents rooms throughout facility (behind beds, baseboards). Major improvement has been made to ceiling and walls being in good repair throughout facility.
#5. Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). Observed dust accumulation to AC vents in rooms 119 and 167. Observed ceiling vents in hallways in need of general cleaning.
#19. Ice shall be handled, transported, stored, and dispensed in such a manner as to be protected against contamination. 15A NCAC 18A .1314 (b). Observed ice chest stored on north hallway unattended and not locked. Improvement from previous report.
#33. Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed staining on pillow cases in rooms 146. Observed staining on sheet in room 263.
*NOTE: EHS Augusta Washington was present during time of inspection. Head of Maintenance and Housekeeping manager were present during time of inspection (Thomas and Lynn). Report emailed to the following
Thomas.lowery@choice-health.net
Sebastian.adams@choice-health.net (Executive Director)
#8 · Facilities conveniently located, clean and in good repair −1
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed toilet chairs throughout with rust accumulation under/behind toilet lids. (123, 182).
Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed detailed cleaning needed to shower rooms throughout to include flooring and bathing fixtures. Observed black build up within shower tiles in south shared spa room and Hampton shared spa room.
#9 · Toilet rooms free of storage, hand wash signs posted −0.5
Toilet rooms shall not be used for storage. See rule .1312 (b). Observed storage not used for bathing stored in south shared spa room and Hampton shared spa room to include wheelchairs, boots, pillows, and large bins.
#21 · Solid waste stored properly, areas clean, facilities for cleaning −2
Solid waste containers, rooms, or designated areas shall be kept clean. 15A NCAC 18A .1316 (c). Observed detailed cleaning needed to soiled utility rooms (bags of trash stored outside of covered containers on the floor).
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). Observed solid waste not covered in soiled utility rooms throughout facility.
#28 · Adequate storage, area clean, items properly stored −0.5
All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). Observed several boxes of patient care items stored on the floor in storage medical supply closet on north hallway.
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). Observed emergency supply closet on north hallway in need of detailed organizing.
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −2
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 hygiene items stored on clean linen carts throughout facility.
May 18, 2022 94 / 100 · 5 violations
Inspector comments: NO POINTS FOR THE FOLLOWING VIOLATIONS:
#19. Ice shall be handled, transported, stored, and dispensed in such a manner as to be protected against contamination. 15A NCAC 18A .1314 (b). Observed cooler of ice stored on rolling cart on lower 100 hallway unlocked and not secured.
#21. 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). Observed dumpster door and lid open. CDI - Door and lid to dumpster were closed before returning to the indoor premises.
#28. All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). Observed patient contact items stored on the floor in storage closet located on lower and upper 100 hallways.
#35. Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c). Observed hair in multiple brushes and combs stored within the salon room.
*NOTE: Head Maintenance Thomas and Housekeeping manager Kecia were present during time of inspection. EHS Jordan McClenic lead inspection with EHS Alexis Welch present. Report emailed to:
#2 · Floors clean, carpet clean, dry, odor free −1
Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed carpet staining throughout facility. REPEAT VIOLATION.
#3 · Walls and ceilings cleanable, clean, good repair −1
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed minor scuff markings to walls, baseboards, and wall joints throughout. Observed old ceiling stains to some ceiling area throughout, EHS advises facility to resurface/repaint old ceiling stains. REPEAT VIOLATION.
#9 · Toilet rooms free of storage, hand wash signs posted −1
Toilet rooms shall not be used for storage. See rule .1312 (b). Observed soiled utility and patient contact item storage in spa rooms.
#16 · Quantitiy and hot water sufficient, backup water supply plan −1
Observed no backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f). REPEAT VIOLATION.
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −2
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 within the facility stating the concentration of the sanitizer being used to clean common linen (per rule 15 NCAC 18A .1319 (b) it should be 50 ppm chlorine or EPA listed sanitizer). REPEAT VIOLATION
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 bottles of personal hygiene items, single use gloves, and other incidental items commingled on clean linen carts throughout the facility. REPEAT VIOLATION
Jul 14, 2021 94.5 / 100 · 5 violations
Inspector comments: NO POINTS FOR THE FOLLOWING VIOLATIONS:
#8. Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed removable toilet seat with staining and rusting in room 275.
#16. Observed an incomplete backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f). EHS emailed facility a template of a backup water supply plan.
#28. All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). Observed patient briefs stored on the floor in storage closet located on lower 100 hallway.
#35. Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c). Observed bed pillows torn in rooms 181 and 240.
*NOTE: EHS Miriam Burkhart was present during time of inspection. Mrs. Casey Christopher was present during of inspection, report emailed to: casey.christopher@choice-health.net
#2 · Floors clean, carpet clean, dry, odor free −1
Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed carpet staining throughout facility.
#3 · Walls and ceilings cleanable, clean, good repair −1
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed stained ceiling near nursing station on West wing and South wing. Observed wall damage behind sink in soiled utility room located on west hallway.
#9 · Toilet rooms free of storage, hand wash signs posted −0.5
Toilet rooms shall not be used for storage. See rule .1312 (b). Observed soiled utility bins and storage in shared spa room located in "Hampton Acres" shared spa room.
#33 · Linen changed when soiled. Soiled linen handled properly −1
Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed staining on bed linen in rooms 115, 146 and 240.
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −2
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 within facility stating the concentration of the sanitizer being used to clean common linen (per rule 15 NCAC 18A .1319 (b) it should be 50 ppm chlorine ir EPA listed sanitizer).
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 bottles of personal hygiene items comingled on clean linen carts throughout facility. REPEAT VIOLATION.
Jan 21, 2021 96.5 / 100 · 4 violations
Inspector comments: No points were deducted for the following:
5. Observed vent filters in need of cleaning in room 112.
**Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).
32. Observed curtain in room 112 with staining.
**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).
#3 · Walls and ceilings cleanable, clean, good repair −1
Observed ceiling with old water stains. Leak is repaired, ceiling needs to be painted.
**Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#8 · Facilities conveniently located, clean and in good repair −1
Observed hoppers not operating. Ensure that hoppers are repaired.
**Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
Observed slow drain in room 112.
**Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
#9 · Toilet rooms free of storage, hand wash signs posted −0.5
Observed wheel chairs stored in the spas. Spoke with staff about relocating these items.
**Toilet rooms shall not be used for storage. See rule .1312 (b).
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
Observed items other than linen stored on linen carts during inspection.
**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).
Jan 16, 2020 95 / 100 · 5 violations
Inspector comments: 15A NCAC 18A .1310 Walls and ceilings shall be kept clean and in good repair. Observed wall damage in room 121 and in soiled utility rooms.
15A NCAC 18A .1319 (a) Observed couches in need of cleaning under cushions.
15 NCAC 18A .1312(b) Keep all toilet equipment clean and in good repair.
Observed spray wand in spa room leaking and in need of repair.
Observed a potential cross connection in laundry room can wash. The hose vacuum breaker backflow prevention should be placed on the bottom of the valve but before the hose.
15A NCAC 18A .1309 Floors shall be free of obstacles to allow for cleaning. Carpeting shall be maintained clean. Observed some storage rooms in need of organizing to keep items off floor to allow for proper cleaning. Observed carpets throughout facility with stains.
Observed bedpans throughout facility. Make sure we are using a hopper to properly clean them in between uses.
Observed waste water backed up in laundry can wash.
#8 · Facilities conveniently located, clean and in good repair −1
15A NCAC 18A .1312(b) Keep all toilet equipment clean and in good repair. Observed shower bed and shower seat dirty in west hall spa. Observed shower chair in north spa room in need of cleaning. Observed hopper in soiled utility room in need of cleaning. Observed toilet in room 115 in need of cleaning.
#14 · Disinfectant accessible, properly used −1
15A NCAC 18A .1312 (f) Clean patient contact items with a disinfectant with appropriate contact time each time. It was stated that the contact that was used was 3 to 5 minutes when the dissifectant should be 10 minutes.
#28 · Adequate storage, area clean, items properly stored −1
15A NCAC 18A .1319 (a) All patient care items shall be stored at least 8 inches off the floor. Observed briefs on floor in several rooms throughout facility and in janitors closest.
15A NCAC 18A .1319 (c) Patient contact items shall be kept clean and in good repair. Observed wheelchair arms and padded seats with tears in them.
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
15A NCAC 18A .1319 (a) All furniture shall be kept clean and in good repair. Observed stains on several chairs and pillows throughout facility.
15A NCAC 18A .1319 (b) Clean bed linen shall be kept clean and in good repair. Observed stains on several sheets and linens throughout facility.
#38 · Handwash lavatory provided wherever food is handled −1
N/A
Sep 13, 2019 95.5 / 100 · 4 violations
Inspector comments: Continued from page 2
8. Observed soiled shower bed in the spa on West hall.
**Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
No points were deducted for the following:
10. Observed urinal not labeled in room 113. Needs to be labeled.
**Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).
Observed urinal on the floor underneath handwashing sink, soiled in room 113.
**All bedpans/urinals/emesis basins shall be cleaned after each use. 15A NCAC 18A .1312 (c).
34. Observed gloves stored on clean linen cart on North hall. Gloves were removed.
**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).
36. Observed interior of microwave in need of cleaning in the refreshment room on West hall.
**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).
#3 · Walls and ceilings cleanable, clean, good repair −2
Observed water stained ceilings on the hallway during the inspection. Per staff roof was recently repaired. Ensure leaks are fixed and paint over stained area.
**Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#8 · Facilities conveniently located, clean and in good repair −1
Observed stained toilet in rooms 147 and 177. Observed storage in hopper in soiled utility closet. Observed soiled hopper on West and South Hall.
**Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
Observed handwashing sink clogged in soiled utility room. Per staff, work order is in place.
**Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
(Continued on last page)
#28 · Adequate storage, area clean, items properly stored −0.5
Observed disposable under wear stored on the floor in the janitor's closet on North, South and West. Ensure that items are not stored directly on the floor. Observed clothing stored on the floor in room 177.
**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 torn pillows in rooms 113, 147 and 298. Ensure that pillows that are torn are removed to prevent moisture from getting inside. Observed torn chair in the library. Needs to be repaired/replaced.
**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).
Apr 23, 2019 95.5 / 100 · 3 violations
Inspector comments: NO POINTS DEDUCTED
#13
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 resident hand washing sinks inside bathrooms measuring 119F on North Hall rooms.
#28
All patient care or consumable items or misc storage containers shall be stored at least 8 inches above the floor to facilitate cleaning and prevent contamination. 15A NCAC 18A .1318 (a). Observed storage directly on floor throughout facility.
#2 · Floors clean, carpet clean, dry, odor free −2
REPEAT
Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed stains on carpet in hallways throughout; Observed water puddled on floor near can wash in laundry room in need of removal /repair; Observed sticky flooring in resident room #121.
#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 water damaged ceilings throughout facility; Observed water damaged / moldy ceiling inside North Janitor closet in need of immediate repair.
#9 · Toilet rooms free of storage, hand wash signs posted −0.5
Toilet rooms shall not be used for storage. See rule .1312 (b). Observed large amounts of storage (wheel chairs) stored within shower area of SPA on WEST Hall.
Aug 8, 2018 94 / 100 · 4 violations
Inspector comments: NO POINTS DEDUCTED
#17
Water fountains clean and in good repair; observed water fountains not operational with dirty mouth guards and standing water in drain basin.
#2 · Floors clean, carpet clean, dry, odor free −1
Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed resident storage directly on floor in resident room #242 ; store above floor to facilitate cleaning. Observed some closets in resident rooms covered with clothing and debris in need of 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 residents rooms having scuffed walls behind beds in need of touch-up painting; Observed numerous areas of ceiling in hallways having water damage in need of repair.
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −2
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 bed frames having old food collected on surfaces in resident room #177; Observed numerous dressers and cabinets in need of furniture pen touch-up.
#33 · Linen changed when soiled. Soiled linen handled properly −1
REPEAT
Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed pillow in poor condition in resident room #274 in need of discarding; Observed sheet with stains in resident room #147.
(points not increased due to improvement).
Jan 23, 2018 94.5 / 100 · 6 violations
Inspector comments: Mr. Kevin, Mr. John, and S. Pepper REHSI present during today's inspection.
13) 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 at 95F in room 112.
28) All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). Observed briefs stored on floor in room 176 and room 268. REPEAT VIOLATION Significant improvement from last inspection.
30) Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c). Observed chemical aerosol stored with medicine in cart in Oasis center. CDI: Chemical removed.
#3 · Walls and ceilings cleanable, clean, good repair −1
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed touch up paint needed throughout facility. Observed damaged wall in rm 142, rm 236 and janitorial closet in northpoint area. Observed staining on wall in rm 142. Observed stained ceiling from leak in southbend area. Observed grout in west lake and northpoint spas to be stained and missing in some areas. Observed door frame in bathroom of 172 with debris on it. REPEAT VIOLATION Improvement from last inspection.
#8 · Facilities conveniently located, clean and in good repair −1
Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed leaking tub in room 280, causing discoloration on tub. Observed shower chair in hampton acres spa with pink build up. Observed west lake spa shower gurnie with staining. REPEAT VIOLATION
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed toilet with heavy soiling in 236. REPEAT VIOLATION
#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 no disinfectant present in hampton acres or northpoint spas. Observed disinfectant to be low in west lake spa.
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
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 stained curtains in hampton acres spa, 280, 236, and 176. Observed stained chair in room 142. Observed stain under couch cushion of room 280. REPEAT VIOLATION
#33 · Linen changed when soiled. Soiled linen handled properly −1
Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b). Observed bins in spas labeled "linen" containing soiled linen.
Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed soiled linen on beds in rooms 280, 275, 268, and 142. REPEAT VIOLATION
#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −0.5
Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c). Observed toileting items on clean linen cart. REPEAT VIOLATION improvement from previous inspection
Jul 11, 2017 93.5 / 100 · 7 violations
Inspector comments: Mr. Kris, Mr. Kevin, J. Blackmon REHSI and M. Adame REHSI present during inspection today.
5) Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). Observed dining room vents in need of cleaning. REPEAT VIOLATION Improvement from last inspection.
13) 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 at 120F in room 117.
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). Observed debris under couch in activity room and room 117. REPEAT VIOLATION Improvement from last inspection.
34) 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 mesh covering on clean linen cart with large enough holes to where adequate protection of linens is not provided. Cart was stored on hallway. Operator reminded to ensure that linens are always adequately protected by a covering or within a storage room.
#3 · Walls and ceilings cleanable, clean, good repair −1
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed molding falling in dining room. Observed minor baseboard damage in oxygen storage room. Observed areas of ceiling throughout facility with water stains. Observed water leaking onto carpet near sprinkler head in main corrider. Observed some wall damage present in storage closets. REPEAT VIOLATION Improvement from last inspection.
#8 · Facilities conveniently located, clean and in good repair −1
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed potty chair in need of cleaing and toilet seat dirty in room 273.
Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed shower gurnie with debris and some standing water in West spa. REPEAT VIOLATION Improvement from last inspection
Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b) Observed faucet in 273 in need of repair. Observed faucet in need of cleaining in 238.
#28 · Adequate storage, area clean, items properly stored −0.5
All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). Observed patient contact items stored under chemicals in storage closet and on housekeeping cart. Observed toileting items stored on the floor in 238, 267 and in storage room. Observed large bottle of soap on the floor in oxygen storage. REPEAT VIOLATION Improvement from last inspection.
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c). Observed staff coffee thermos stored in drawer with medicines for residents. Observed single service medicine cups to not be protected on med cart.
#31 · Feeding syringes and oral suction catheters handled properly, tube-feeding bags changed per instructions −1
Feeding syringes which are reused shall be labeled with the patient's name and date opened, shall be disassembled and rinsed after each use, and shall be disposed of within 24 hours of first use. 15A NCAC 18A .1318 (d). Observed feeding syringe to not have a label identifying it.
Feeding syringes and oral suction catheters shall be stored in a clean container. 15A NCAC 18A .1318 (d). Observed feeding syringe stored directly on bedside table.
#33 · Linen changed when soiled. Soiled linen handled properly −1
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). Observed soiled linen overflowing out of soiled linen basket in "Hampton Acres" spa and in soiled linen room.
Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed minor stains on linen in 238. Observed torn sheet in 147. REPEAT VIOLATION Improvement from last inspection.
#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −1
Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c). Observed hair remaining in rollers in "Oasis" salon. Observed toileting items present on clean linen cart. REPEAT VIOLATION
May 10, 2017 94.5 / 100 · 5 violations
Inspector comments: . Mr. Kevin and Mr. Kris present during today's inspection.
5)Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). Observed vents throughout building in need of cleaning.
30)Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c). Observed north side medication cart with unprotected cup lips. All other med carts had items properly protected.
33)Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed soiled linen on beds in rooms 117 and 275.
#3 · Walls and ceilings cleanable, clean, good repair −1
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed wall damage in several areas throughout facility, including in janitor closets, in the west nourishment room, and in room 274. Room 275 had tile damage near the AC. REPEAT VIOLATION
#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 underside of shower chairs in spas to have pink and black build up. REPEAT VIOLATION
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). . Observed several bathrooms that were not clean. Observed some toilet fixtures to be in disrepair.
#28 · Adequate storage, area clean, items properly stored −1
All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). Observed that in several rooms, patient contact items (clothes, briefs) were stored on the floor in closets. REPEAT VIOLATION
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
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 furniture throughout facility in need of cleaning. Several common area couches had food build up between cushions. Several chairs were severely stained. The couch in room 301 had crumbs under the cushions as well. Observed blinds in rooms throughout facility in need of dusting. REPEAT VIOLATION
#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −0.5
Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c). Observed pillows in rooms 274 and 263 to be torn and damaged. Observed clean linen cart to have a water bottle stored amongst linen. Observed clean linen cart to have toileting items stored amongst linen.
Nov 7, 2016 94.5 / 100 · 6 violations
Inspector comments: General Comment:
#1. Reattach transitional floor molding to floor in resident room near entrance to bathroom and remove tape from flooring. Observed stain on carpet across hallway from shower south. Clean spot on carpet.**Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b).
#4. Replace blown light bulbs in light fixture or repair light fixture in common bath/shower in shower north.**All areas shall have sufficient illumination. Maintain 10 foot candles of light at 30 inches above the floor in all areas other than food service areas. 15A NCAC 18A .1311 (a).
#10. Observed (1) bed pan not labeled in bathroom shared between two private rooms. One room was a show one and the other was being used. ***Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).
Mr. Kris Thompson and Reader present at time of inspection.
#3 · Walls and ceilings cleanable, clean, good repair −1
Observed some slight wall damage and some area of wall needing some touch-up paint. Continue to make necessary repairs to walls throughout in residents room, hallway and janitor closet. Repair wall around base of can wash in janitor closet. Patch hole in wall in room 166 and install door stopper if necessary. Monitor ceiling through facility and make any ceiling repairs if needed. Facility has bided out roof repair/replacment; facility will just have to make final decision Tighten loose door handle to bathroom in room 261. Tightly secure any loose base board molding in janitor closet. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#8 · Facilities conveniently located, clean and in good repair −1
Observed underside of shower bed padding soiled. Observed broken leg on shower chair in bathroom between 304 and neighboring room. Thoroughly clean underside of padding on shower chair. Repair leg on shower chair or replace. Continue to replace pitted faucet fixtures on hand washing faucet throughout in bathrooms. Maintenance man (Mr. Kevin) has been replacing faucet fixtures throughout in rooms. Observed grout missing from between floor tiles in shower area in shower south. Regrout floor tiles in shower!
Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
#17 · Water fountains clean, good repair, properly regulated −1
Observed water nozzle on water fountain soiled near south shower. Thoroughly clean water nozzle on water fountain near south shower. Clean other water fountains throughout facility even if units are not being used and keep clean. Just remove water fountains.
Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a).
#28 · Adequate storage, area clean, items properly stored −1
Observed briefs stored on the floor in several closets within rooms. Do not store or place briefs/diapers on the floor. Store briefs on top shelving within residents closet. Observed clothes storage on the floor in closet area of one room. Store resident clothes off the floor. Store items on hanger and hang clothes up or fold items up and place in residents dresser drawer.
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
Replace damaged mattress in room 304. Tighten loose foot board on resident bed. Thoroughly clean cover on chairs in residents room. Tightly secure loose laminate on counter top at nourishment stations. Observed (1) damage pillow in resident room. Discard and replace damaged pillow.
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 stains on (1) jerry chair padding in resident room. Thoroughly clean padding on jerry chair. Observed some hair in beauty salon sink. Thoroughly clean and disinfect beauty salon sink between different resident hair wash. Observed hole on (1) fitted sheet on bed. Discard and replace any linen with holes present.
Jun 22, 2016 91.5 / 100 · 7 violations
Inspector comments: General Comment: #4. Replace blown light bulbs in light fixture in storage room and janitor closet or repair light fixture.**All areas shall have sufficient illumination. Maintain 10 foot candles of light at 30 inches above the floor in all areas other than food service areas. 15A NCAC 18A .1311 (a). #26. Observed damaged vinyl siding on facia and soffit of building. Repair or replace damaged vinyl siding on facia and soffit of building.***There shall be no fly or mosquito breeding places, rodent harborages, or undrained areas on the premises. 15A NCAC 18A .1317 (c). Mrs. McAferty, Mrs. Walker and Mr. Reader present at time of inspection.
#3 · Walls and ceilings cleanable, clean, good repair −1
Continue to repair corner and edges of wall in residents' rooms and touch-up paint. Secure loose rubber cove base moulding in storage rooms. REPAIR ANY AND ALL ROOF LEAKS, SPRINKLER SYSTEMS LEAKS OR CONDENSATION LINE/VENTILATION DUCT WORK LEAKS AND REPAIR AND REPAINT CEILING THROUGHOUT IN HALLWAY AREAS AND FRONT ENTRANCE AREA. Touch-up paint door framing at main entrance and to residents' rooms and bathrooms. Clean carpet in common sitting area. Regrout floor near toilet in common shower/bath area. Repair wall in charting area! 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 pitted faucet fixtures on hand washing sinks throughout in residents' bathrooms and common bath/shower areas. Replace pitted faucet fixtures on hand washing sinks. Observed loose toilet seats in common shower/bath area and residents' bathrooms. Tighten loose toilet seats. Observed damaged toilet seats in several rooms(laminate worn from seat and damaged on underside); replace damaged toilet seats. Observed shower/bath/toilet fixture soiled in residents' bathrooms and common bath/shower areas. Thoroughly clean underside of raised toilet seat, trough on bed shower, shower chairs, raised toilet seat funnel and shower bed pads. Replace damaged arm rest on shower chair. Clean base of bath tub in resident room. Repair base of shower wall in common shower/bath. Thoroughly clean base of shower wall in common shower/bath. 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)
#17 · Water fountains clean, good repair, properly regulated −1
Thoroughly clean water fountains located in hallway area. Reduce water pressure on (1)water fountain so water does not splash onto the floor. Either repair out of order water fountain, keep it clean at all times or remove water fountain from wall.
Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a).
#28 · Adequate storage, area clean, items properly stored −1
Observed packages of briefs stored on the floor in residents' closets within rooms. Remove cases of briefs off the floor. Also observed case of brief stored on the floor in resident room and the case/cardboard showed evidence of contamination from floor being mopped. Observed residents dirty clothes stored/ placed on floor in base of closets. Store soiled/dirty clothes in soiled linen basket or bag in resident closet or soiled linen bin in soiled linen room. Observed sleeving of single service articles stored in hand washing sinks in nourishment area. Observed padding to equipment stored under hand washing sinks. 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).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed loose and missing laminate on base of dressers in rooms. Observed stains on chair cushions in common area and (1) resident room. Observed trash and debris under couch cushions in all common sitting area. Secure and replace missing laminate on base of dressers in rooms. Clean stains from couch cushions and chairs. Clean under couch cushions. Tighten head board up on bed in (1) 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).
#33 · Linen changed when soiled. Soiled linen handled properly −2
Observed soiled and damaged linen(sheet and fitted sheets) on beds already made up. Also observed some linen on bed that was torn and had holes present.
Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).
#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −0.5
Observed damaged arm rest on wheel chairs and jerry chair. Replace damaged arm rest on wheel chairs and jerry chair. Replace damaged padding used on therapy table in therapy room.
Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).
Sep 17, 2015 90 / 100 · 8 violations
Inspector comments: #10 Observed bed pan not labeled in 301. Label all bed pans#12 Observed paper towels not present at hand wash sink in rooms 301 and 298. Room was not occupied and paper towels were provided on site. Mr. Reader, Ms. Walker, Ms. Duncan were all present during inspection.
#3 · Walls and ceilings cleanable, clean, good repair −1
Repeat Non Compliance: Observed some areas with water stains. Visible repairs have been made. Quotes from FlexaCoat were seen. Continue to complete repairs. Improvement seen from previous inspection. Observed wall in South Nourishment room in disrepair from previous soap dispenser.**Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#8 · Facilities conveniently located, clean and in good repair −2
Repeat Non Compliance: Observed underside of shower chair rusted and soiled in room 266, 182, west shower chair. Observed slow drain sink in room 182. Observed eye wash in West shower hanging off wall. **Keep all hand washing facilities clean and in good repair. 15A NCAC 18A .1312 (b)**Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
#14 · Disinfectant accessible, properly used −2
Repeat Non Compliance: Observed disinfectant not present in North shower room, and pulled and refilled when entering shower room in HA.Observed purple top disinfectant wipes not present in PT room at time of inspection. Correct wipes were provided before leaving PT room. **A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).
#24 · Vermine excluded −1.5
Repeat Non Compliance: Observed ants present in resident room #182 trash can, and in South shower room near foot cleaning equipment. Observed live mouse caught on glue board located in back room of laundry. **Effective measures shall be taken to keep flies, rodents, cockroaches, and other vermin out of the establishment and to prevent their breeding or presence on the premises. 15A NCAC 18A .1317 (a).
#28 · Adequate storage, area clean, items properly stored −1
Repeat Non Compliance: Observed pull ups, clothes, and other items stored on floor in residents closets. Rooms included, but not limited too: 266, 173, 182, Observed humidifier bottle stored on floor in oxygen room. Observed empty linen carts, shelving, and other items stored behind storage unit. Observed excessive equipment stored in West shower and wheel chairs stored outside under porch/covered area. **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).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Repeat Non Compliance: Observed 2 small stains on furniture in library near west/north halls. Observed 1 stain on resident chair next to closet in room 173. **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).Improvement seen.
#33 · Linen changed when soiled. Soiled linen handled properly −1
Observed linen in need of cleaning in room 182. Keep all linen clean and in good repair. Observed extra bagged soiled linen on top of covered soiled linen trash can. Improvement seen with stained linen. **Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).
#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −0.5
Observed shower cart with residue present in West shower room, with coat hangers touching the floor in laundry room. **Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).**Patient contact items that become contaminated during use shall be cleaned and disinfected after each use. 15A NCAC 18A .1319 (c).
May 27, 2015 91.5 / 100 · 6 violations
Inspector comments: #2 Observed carpet stains present in spotted areas of facility. Carpets shall be kept clean and odor free. 15A NCAC 18A .1309(a)#5 Observed 1 A/C vent collecting debris in room 123. All other vents were in good repair. Clean vent in room 123 and continue to keep vents in good repair. 15A NCAC 18A .1311(b)#15 Observed 1 shower wand missing back flow preventer in North Spa. Provide back flow prevention device. Improvement seen as to all other shower wands present in spa and resident rooms containing back flow prevention devices. 15A NCAC 18A .1313(d)#24 Observed 1 ant present in South electrical storage closet. Continue to utilize pest control company and keep property free of insects and vermin. 15A NCAC 18A .1317(a)#30 Observed 1 soiled pill crusher on med cart on West 2. Pill crushers shall be cleaned regularly and when visibly soiled. 15A NCAC 18A .1318(c)#36 Observed South resident refreshment room collecting debris in cabinets as well as in bottom of fridge. Keep all food service equipment clean and in good repair.15A NCAC 18A .1320(c)Observed bottle of sanitizer sitting on low shelf in library room of North Hall. ENSURE ALL CLEANING PRODUCTS ARE STORED AWAY AND NOT LEFT OUT IN REACH OF RESIDENTS.Mr. Reader was present during inspection. Continue to complete repairs. Facility has shown visible improvement from past inspections.
#3 · Walls and ceilings cleanable, clean, good repair −1
Repeat Non Compliance: Observed water stained ceilings throughout. Corrections are visible continue to touch up paint and correct leaks when occurring. **Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#8 · Facilities conveniently located, clean and in good repair −1
Repeat Non Compliance: Observed residue collecting under 1 shower chair in North Spa. Improvement was made from previous inspection. Observed eye wash station in disrepair. Repair eye wash bowl. **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).
#14 · Disinfectant accessible, properly used −2
Repeat Non Compliance: Observed disinfectant not present in North Shower spa. Observed disinfecting wipes not present at time of inspection in therapy room. Correct wipes were provided by report completion. **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 briefs stored on floor near common storage/time clock and outside white shed. Observed plastic cups stored on floor in common storage. Observed wheel chair stored in South Spa and other rolling equipment stored in West Spa. **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).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −2
Repeat Non Compliance: Observed residue present on couch cushion in room 299, stain on couch in South common area, hole in door of room 175, stains on couch in North Library, end of bed bolts off track in room 240, book shelf in disrepair in North Library, and ripped arm rest of resident chair in storage shed. **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 −2
Observed soiled bag of linen stored on shower stretcher in West shower spa.**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 11, 2014 91 / 100 · 6 violations
Inspector comments: #1 Observed spa flooring throughout of facility with spots of grout peeling on floor in need of repair. ** Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b).#5 Observed 1 A/C vent in need of cleaning in room 120. **Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). #12 Observed paper towels not present in West Spa Room. Towels were restocked before leaving spa room. All other handwash stations present. **Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). #24 Observed several dead insects present on floor in corner of clean linen storage closet near laundry room. All items were off floor. Area just in need of cleaning. **Effective measures shall be taken to keep flies, rodents, cockroaches, and other vermin out of the establishment and to prevent their breeding or presence on the premises. 15A NCAC 18A .1317 (a).#28 Observed wheel chair stored in West Shower room in need of removal. Observed single service cups stored on floor in West Storage closet.Observed 3 oxygen tubes in packets on floor in North Oxygen Storage room. Keep all items off floor.**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).#36 Gaskets repaired from previous report. Gaskets in North & West Hall Nourishment (freezer) in need of cleaning inside tracks. Microwaves found in West & South Hall Nourishment in need of cleaning.**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).Mr. Reader present during inspection.
#3 · Walls and ceilings cleanable, clean, good repair −1
Repeat Non Compliance: Observed water leak in South Nourishment Room. Leak was found upon trimming overhanging limbs on roof after previous heavy rain. Note: Crack in ceiling in West Hall has been patched and previous water stains in ceiling have been addressed and repaired. Observed bottom of spa wall tiling damaged in need of reattach.**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 rip in blue shower mattress pad, ripped top side of red plastic shower chair, black residue present on bottom side of shower curtain from where moisture collects and sticks vinyl. Observed 2 shower chairs with debris present on underside of seat in need of cleaning in West Hall Spa. Observed underside of toilet chair soiled in room 120. **Keep all bathing equipment clean and in good repair. 15A NCC 18A .1312 (a) and (f).**Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
#14 · Disinfectant accessible, properly used −1
Observed disinfectant not present (readily accessible) in shower spa's throughout facility. Provide disinfectant to all showers. **A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −2
Repeat Non Compliance: Observed debris residue present on inside drawers near corners of dividers on South Hall with loose pills present in back of med cart throughout.**Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Repeat Non Compliance: Observed stains on sofa on top side (red residue) in need of cleaning with debris present under cushions throughout common areas of facility. Observed slight tear in several mattress' with stain present on mattress and gum on surface of mattress in room 268; stain on dividing curtain in room 178 with multiple white plastic pillows with tears on surface. **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 −2
Repeat Non Compliance: Observed linen soiled in room 261 next to added pad under top layer sheet as well as in room 178. Repeat Non Compliance: Observed linen with holes present on linen carts throughout facility and in rooms 178, 268 with rip in comforter (top left corner) in room 261.**Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).
Sep 8, 2014 87.5 / 100 · 10 violations
Inspector comments: 4. Replace lighting in library and in hallways of facility. **All areas shall have sufficient illumination. Maintain 10 foot candles of light at 30 inches above the floor in all areas other than food service areas. 15A NCAC 18A .1311 (a).5. Observed ceiling vents, A/C wall vents in need of cleaning in multiple rooms. **Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). 19. Observed ice bucket in nourishment room in need of monitoring of black residue build up before restocking with ice. Plastic liner not necessary for ice scoops. Plastic container works fine just ensure items are cleaned accordingly.**Ice shall be handled, transported, stored, and dispensed in such a manner as to be protected against contamination. 15A NCAC 18A .1314 (b). **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).32. Observed stain on sofa furniture in West Hall, including debris present underneath cushions in library. **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). Areas were isolated and debris was minimal concerning furniture. 34. Observed inside of dryer with heat damage to tracks in need of cleaning, repairing, replacing. **Laundry areas and equipment shall be kept clean. 15A NCAC 18A .1319 (b) and .1312 (a). 36. Observed debris build up in popcorn maker located in activity room in need of cleaning. Repair gaskets **All utensils and food contact surfaces of equipment used in the preparation, service, display, or storage of potentially hazardous foods shall be cleaned and sanitized prior to each use. 15A NCAC 18A .1320 (c).**All utensils and food contact surfaces of equipment used in the preparation, service, display, or storage of potentially hazardous foods shall be cleaned and sanitized prior to each use. 15A NCAC 18A .1320 (c).
#3 · Walls and ceilings cleanable, clean, good repair −1
Observed wall/ceiling damage in facility throughout. Observed large crack in ceiling in West hall. Ceiling stains throughout facility were found in storage rooms, hallways, etc. Baseboards in need of repair in storage closets and in spa' s. **Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#8 · Facilities conveniently located, clean and in good repair −2
Repeat Non Compliance: Observed loose toilet seat loose in room 280 in need of tightening, bathroom chairs, spa equipment including shower chairs, underside of lay tables in disrepair/soiled in need of cleaning, sinks with slow drains in need of repair for future clogging, **Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).**Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −1
Repeat Non Compliance: Observed bed pan not labeled in room 295. Label all bed pans.**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).
#13 · Lavatory and bathing hot water between 100 and 116 F −1
Repeat Non Compliance: Observed hot water temps at handwashing sinks reaching over 116F and topping out at 125F in resident rooms on North Hall. Water temps fell back down in range as inspection went on. **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).
#14 · Disinfectant accessible, properly used −1
Repeat Non Compliance: Observed bottle of disinfectant not properly labeled in North Spa shower. Bottle in need of proper labeling. **Where disinfectants are mixed on site, the concentration of the mix shall be assured by use of a metering pump, measuring device or chemical test kit. 15A NCAC 18A .1312 (f).
#15 · Approved water supply, no cross-connections −2
Observed shower wands missing backflow preventers in patient rooms throughout. Continue to provide backflow on shower wands.**Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).
#17 · Water fountains clean, good repair, properly regulated −1
Repeat Non Compliance: Observed water fountain with low water pressure on East Hall. Water fountain pressure shall be adjusted to reach height above nozzle. Observed calcium build up around base at several water fountains. **Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −2
Repeat Non Compliance: Observed debris/residue on inside drawer liners, small med cups not properly inverted, chemicals stored next to exposed cup. **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).
#33 · Linen changed when soiled. Soiled linen handled properly −1
Observed linen, comforters, and bedding soiled/ripped in resident rooms, clean linen closets, and clean linen carts throughout facility. Linen provided shall be maintained clean and in good repair. **Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).Observed bag of soiled clothing in North Spa. **Soiled linen shall be placed in a covered container or bag at the point of use stored and handled so as to contain and minimize aerosolization of and exposure to any waste products. 15A NCAC 18A .1319 (b).
#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −0.5
Observed bag of diapers stored on floor in hallway closet, clothes hanger stacked on top of each other not 8" off floor, and clean bag of clothes stored on floor in laundry room. **Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).
May 14, 2014 88 / 100 · 10 violations
Inspector comments: . General Comments. 12. Observed no paper towels in North Nutrition room and North shower room. Dispensers were refilled during the inspection. 14. Observed bottle of cleaner labled disinfectant in the North shower room. Properly label all chemicals.17. Observed one drinkning fountain on the East hall with low pressure and one on the West hall with high pressure. Adjust pressure accordingly. 26. Observed broken particle board on ground behind maintenance shed. Remove potential harborage areas for vermin. 32. Observed cumbs under sofa cushions throughout and stains on chairs throughout. Observed split gaskets on refrigerator in West nutrition room. Thoroughly and frequently cleanfurniture. Replace split gasket on refrigerator.DO NOT REMOVE OR OBSTRUCT GRADE CARD! Grade card must stay posted at all times! Once violations have been corrected, may call for a regrade; Shawn Blackmon (704)534-4542.
#3 · Walls and ceilings cleanable, clean, good repair −1
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed wall damage and ceiling damage in guest rooms, hallways, storage closets, med-rooms, and bathrooms throughout. Repair wall and ceiling damage and touch-up paint on repaired areas.
#4 · Lighting at least 10 foot candles 30 inches above floor −1
All areas shall have sufficient illumination. Maintain 10 foot candles of light at 30 inches above the floor in all areas other than food service areas. 15A NCAC 18A .1311 (a). Observed light fixtures not properly operating in North Shower room and East Shower room. Repair light fixtures or replace blown light bulbs to ensure adequate lighting.
#8 · Facilities conveniently located, clean and in good repair −2
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed loose toilet seats in patient rooms and community shower room. Tighten or replace damaged toilet seats. Observed 3 bedpan lugs out of order; only 1 functioning. Repair.Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed build up on bottom of shower seats in North shower room and under padding of shower stretcher. Thoroughly clean bottom of bathing equipment.Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b) Observed laminate on front of sinks missing. Replace lamiante or seal wood so that it is non-absorbant.
#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −1
Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c). Observed paitient bed pans in rooms not properly labeled. Keep patient bed pans labeled with name and date.
#11 · Hand sinks used only for intended purpose −1
Except for the stipulations stated in rule .1312 (d), handwashing sinks shall only be used for handwashing. 15A NCAC 18A .1312 (d). Observed handwahsing sinks with soiled dishes stored in North nutrition room and West nutrition room.Only use handwashing sinks for handwashing, Dump soiled dishes in kitchen dump sink.
#15 · Approved water supply, no cross-connections −2
Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d). Observed no backflow preventers on shower wands in patient rooms throughout. Provide back flow preventers on shower wands.
#19 · Ice protected, dispensed, equipment clean in good repair −2
Observed microbial growth inside ice-machine in dining room and inside ice scoop container in the West nutrition room.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).Thorghouly and regularly clean the ice maker. Ice scoops and ice chests should be cleaned every 4 hours.
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c). Observed heavily soiled pill crushers on all medication carts. Regularly clean pill contactsurfaces where build up is occuring. Obseved soiled drawers on medication cart.Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c). Observed single service cups stored with patient lip contactsurfaces not protected. Do not over-stock med carts with single service cups.
#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −0.5
Observed adult diapers stored on floors of patient closets. Obsevred single service articles and paper towels stored on floor in outside storage shed. Observed wheelchair with damaged arm rest, damaged mat in room 272, tear in padding of "gerry chairs" ,and crumbs under seat cushions of sofas throughout. Move patient contact items up off of floor. Repair or replace damaged arm rest on wheel chair. Replace damaged mat in room 272. Keep all patient contact items properly stored and in good repair. Store patient contact items completely separated!(hair brushes, combs, lotions, etc.)
#40 · Food brought by employees or visitors handled properly −0.5
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 food not properly labeled in refrigerator on east and north nutrition room. Improperly labeled items were discarded.
Sep 20, 2013 90 / 100 · 8 violations
Inspector comments: 12. Observed no paper towels in the soiled utilities room on North hall (improvement shown).Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). 13. Observed hot water at 123F in room 302, and 124F in room 296 on the North hall... This end of the hall does not have any residences due to low census. When rooms are filled, ensure water is at proper range.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).17. Observed pink & black build up in a water fountain on the South hall.Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a).32. Observed a few rooms with dressers in disrepair. All other dressers have been replaced. (improvement shown)Observed 1 torn mattress in room 279.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. Observed linen cart stored uncovered half way between the dirty and clean side of the laundry room.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).Mr. Kevin Reader present.
#1 · Floors easy to clean, no obstacles, drains where needed −1
Repeat Non-Compliance: Observed excess storage on the floor in both closets in room 178, and in the storage room on West hall.Floors shall be free of obstacles to cleaning. 15A NCAC 18A .1309 (a).
#3 · Walls and ceilings cleanable, clean, good repair −1
Repeat non-compliance: Observed missing baseboards, and wall damage (improvement shown) throughout facility.Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#4 · Lighting at least 10 foot candles 30 inches above floor −1
Repeat Non-Compliance: Observed low levels of light in the North hall's soiled room & shower room, and in the West hall shower room due to bulbs being out.All areas shall have sufficient illumination. Maintain 10 foot candles of light at 30 inches above the floor in all areas other than food service areas. 15A NCAC 18A .1311 (a).
#8 · Facilities conveniently located, clean and in good repair −2
Repeat Non-Compliance: Observed stretcher pad in disrepair- West hall.Repeat Non-Compliance: Observed loose toilet seats in North Hall rooms 296, 302, South hall's spa, and in the therapy's restroom.Repeat Non-Compliance: Observed rusty & stained elevated toilet seat in West shower room.Observed calcium build up on shower head on North hall, brown residue collecting on the shower wand head in the West shower room. -Observed leaking hopper- West hall. **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).
#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −1
Repeat Non-Compliance: Observed bedpans in multiple restrooms on the South & West Halls not labeled.Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).
#14 · Disinfectant accessible, properly used −1
Repeat Non-Compliance: Per CNA, the shower equipment is sprayed with disinfectant then wiped clean. Ensure the directions on the label are followed. The disinfectant being used has a 10 MINUTE contact time.The manufacturer's instructions shall be followed for cleaning equipment with pumps. See rule .1312 (f).
#19 · Ice protected, dispensed, equipment clean in good repair −2
-Repeat Non-Compliance: Observed ice chests accessible to the residences stored unlocked unattended on halls and in the dining room.Ice shall be handled, transported, stored, and dispensed in such a manner as to be protected against contamination. 15A NCAC 18A .1314 (b).-Observed debris floating in the bottom of the ice bin on the North hall.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
Repeat Non-Compliance: Observed residue and debris collecting in the med cart drawers.Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).Repeat Non-Compliance: Observed clean items stored on the side with the trash and sharps container.Observed cups stored unprotected on the med carts.Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c).
Source: Mecklenburg County Public Health – Environmental Health public inspection portal (search for “ROCKWELL PARK REHABILITATION AND HEALTHCARE CENTER” or State ID 2060400034). Inspection type (routine vs. follow-up) is not published in the county's data.