99.5/ 100

MECKLENBURG HEALTH & REHABILITATION

Name: Mecklenburg Health & Rehabilitation
Address: 2415 Sandy Porter Rd, Charlotte, NC, 28273, US

2415 SANDY PORTER RD, Charlotte, NC 28273

Rest/Nursing Homes · NC permit/State ID 2060400037

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Latest result99.5 / 100

Last inspectedJan 15, 2026

Inspections on record23

On record sinceAug 8, 2013

Score history

Aug 8, 2013Higher is betterJan 15, 2026

Inspections & violations

Jan 15, 2026 99.5 / 100 · 1 violation

#5 · Ventilation equipment clean, good repair −0.5

.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed dust buildup in a/c filters in various resident rooms throughout facility. Keep clean.

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Jul 24, 2025 99.5 / 100 · 2 violations

#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 at handsink in resident room 116 at 122F. Ensure hot water is between 105-116F.

#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair −0.5

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Feb 7, 2025 98 / 100 · 1 violation

#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 scuffed walls in various areas throughout facility. Repair. REPEAT

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Jul 8, 2024 97 / 100 · 4 violations

#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 inside resident rooms in need of repair throughout. Observed active leak on ceiling in service hall area in need of repair.

#5 · Ventilation equipment clean, good repair

NO POINTS DEDUCTED .1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed vents inside bathrooms near nursing station rusty and in need of cleaning.

#9 · Bedpans, urinals, bedside commodes and emesis basins properly cleaned and disinfected

NO POINTS DEDUCTED .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 urinal basin stored inside toilet room without name and labeling in room #110.

#30 · Medication carts clean; sharps containers attached; food, utensils, medication and medication dispensers properly handled −1

.1318 (a) Sharps containers located on medication carts shall be attached or secured to the medication cart to prevent the sharps contained from spilling. Observed sharps container stored inside spa not attached to any surface with the ability to spill / accessed.

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Apr 11, 2024 97.5 / 100 · 4 violations

#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 door frames throughout having areas of missing / damaged paint in need of re-painting / repair.

#12 · Bathing facilities properly equipped, equipment cleaned and disinfected

NO POINTS DEDUCTED .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 no disinfectant available during inspection inside spas, recommendation to keep spray disinfectant inside spas to use on shower chairs and equipment.

#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 cabinet doors missing / broken and damaged throughout inside soiled utility / supply rooms / clean supply rooms in need of repair / replacing. Observed wheel chairs stored inside hallways with damaged cushions (arm rests) exposing absorbent material in need of replacing.

#52 · Vomitus and diarrheal clean up supplies; written clean up procedures available and complete −1

.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 vomit / diarrhea procedures available during inspection. Procedures given to admin.

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Sep 15, 2023 96 / 100 · 9 violations

#5 · Ventilation equipment clean, good repair

.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed minor dusts on air filter, ceiling vents in some rooms. 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 hand sink in one of the spa rooms was blocked with no access to hand wash by bath bed and toilet chair. CDI- Maintenance removed items to provide access at the time of inspection. Ensure to provide access to hand washing sink at all time. Observed rusted toilet chair in room 105, 106, need repair or replace and keep in good repair.

#8 · Toilet rooms free of storage, handwash signs posted −0.5

.1312 (b) A sign shall be posted in each toilet room for institution employees, directing them to wash their hands after each visit to the toilet room and before returning to work. Observed no hand washing sign in the restrooms where staff have access. CDI- Hand washing signs provided at the time of inspection.

#10 · Handwashing facilities properly located and equipped −1.5

.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices. Observed no soap in supply room on 100 hall. The paper towel dispensers without batteries or paper towels were out from it in room 112, spa rooms, supply storage rooms, soiled rooms. Ensure to provide all hand washing supplies at all hand sinks at all time.

#17 · Back-up water supply plan available and complete

.1313 (e) The institution shall have a written plan to obtain a backup water supply in the event that the institution's primary water supply is interrupted for more than four consecutive hours. The written plan shall identify a backup water supply or alternate source of water that provides two liters of potable water per day per resident and institution employee for drinking and potable water for food preparation, hand washing, bathing, cleaning, dishwashing, laundry, and disposal of bodily waste. This may include a plan for relocating residents to a facility with a water supply that satisfies Paragraph (a) of this Rule. If an institution's primary water supply or backup water supply becomes unsafe for human consumption, then the water sources within the institution, such as sink faucets, shall be labeled or hooded to prevent their use, and the administrator shall provide potable water for use by the institution's residents and employees. -Observed the facility with incomplete plan for water back up supply. EHS email the checklist for the plan to the administrator, details discussed at the time of inspection. The facility will put the plan together and have it complete by next inspection.

#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 and water cooler cart left out on the hallway in front of nourishment room. DCI- the cart put back in the lock nourishment room.

#30 · Medication carts clean; sharps containers attached; food, utensils, medication and medication dispensers properly handled

.1318 (a) Medication carts shall be kept clean. Observed medication carts need cleaning, spilling of liquid medication and debris inside.

#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 the facility has obtain the laundry records of august, September and November of 2022, and August of 2023. The facility need to keep all records on file as how often service was provided.

#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 the refrigerator in the nourishment rooms need a thermometer inside for the temperature indication.

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Dec 14, 2022 97 / 100 · 7 violations

#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 cracked floor tiles in supply storage room and inside Med room.

#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 wall damage inside the supply storage room and the med room. Observed wall damage in the Main laundry room near the dryers and the eyewash station. Observed wall damage above the mop sink in the utility closet in Hallway B. Observed ceiling dirty/stained near vents in the rehabilitation room. Wall damage was also observed in the Recreation center.

#3 · Ceiling attachments cleanable, clean, good repair −0.5

.1310 (b) Light fixtures, fans, conduits, and heating, ventilation, and air conditioning vents shall be kept clean and in good repair. Observed missing ceiling vent covers in the soiled utility room and in the Rehabilitation room.

#7 · Facilities provided, accessible, clean, good repair

#11 · EPA registered disinfectants used according to manufacturers' instructions; approved testing methods and devices used

.1312 (e) EPA registered disinfectants shall be used in accordance with the manufacturer's instructions. When EPA registered disinfectants are mixed and prepared by institution employees, a measuring device, chemical testing device, or the methods and devices prescribed by the chemical manufacturer shall be used to prepare the concentration of chemicals in accordance with the disinfectant's label and the manufacturer's instructions. No disinfectant was provided inside the Spa in Hallway B. CDI- Disinfectant wipes were provided for the Spa during the inspection.

#12 · Bathing facilities properly equipped, equipment cleaned and disinfected

.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 soiled shower chair inside the spa in Hallway B.

#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair −0.5

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May 19, 2022 96 / 100 · 3 violations

Inspector comments: No points deducted:#3– Keep all walls and ceilings clean and in good repair. #8–Observed rusting toilet chair in room 214. NOTE: Observed renovations occurring during inspection. D wing almost completed.

#19 · Ice protected, dispensed, equipment clean in good repair −1

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). Observed black residue buildup on inner surface of nourishment room ice machine.

#21 · Solid waste stored properly, areas clean, facilities for cleaning −2

' 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 two dumpsters on the premises without drain plugs.

#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1

Unused medication cups shall be kept covered or inverted. 15A NCAC 18A .1318 (c). Observed unused medication cups on medication carts with food contact surface stored above or outside of plastic cover. Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c). Observed soiled pill crushers on multiple medication carts. Regularly clean pill crusher to remove debris.

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Nov 19, 2021 96.5 / 100 · 3 violations

Inspector comments: No points deducted for the following violations: Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c). Observed soiled pill crusher on med cart in wing 200. Clean pill crusher to remove debris. Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b). Observed handwashing sink in laundry room coming apart from wall. Repair calking at handwashing sink. Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b). Observed damaged shower floor tiling in spa in wing 100 near room 118. Repair shower floor tile. NOTE: Facility is under renovations. Observed new flooring and wall paint, etc.

#2 · Floors clean, carpet clean, dry, odor free −1

Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed dirt and debris in supply room and janitor's room in the 100 wing and in the soiled utility room in the 200 wing. Clean floors to remove dirt and debris.

#3 · Walls and ceilings cleanable, clean, good repair −2

Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed ceiling leak at light near room 226. Manager stated maintenance order has been put in place and awaiting repair. Observed floor paneling coming apart from wall near mop sink and damaged paint in janitor's closet in wing 100. Repair floor paneling and paint on wall.

#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 boxes of patient care items stored on floor in storage closets and environmental service room. Properly store items off the floor. Observed regular chair stored in spa.

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May 12, 2021 96 / 100 · 2 violations

Inspector comments: No points deducted: #12--Observed soap missing in restroom in room 208. Resident in hospital at time. #30--Observed cups/single use items stored unprotected on med carts. #32--Observed separation curtain stained in 200 hall spa. Facility will start remodeling soon. Was supposed to start on 5/11, but did not due to gas shortage. Covid 19 restrictions, no signature required.

#3 · Walls and ceilings cleanable, clean, good repair −2

Observed wall damage at door near room 206, observed broken wall tiles in 200 hall spa, and paint peeled above hand sink in laundry room.

#8 · Facilities conveniently located, clean and in good repair −2

Observed clogged toilet in 208, stains in tub in 200 spa, and hand sink needing to be resealed to wall in laundry room. Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed spa room shower stalls with black grout. Keep all handwashing 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).

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Nov 23, 2020 95.5 / 100 · 4 violations

#1 · Floors easy to clean, no obstacles, drains where needed −1

Observed damaged floor tiles in spa rooms. Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b).

#3 · Walls and ceilings cleanable, clean, good repair −2

Observed damaged wall behind toilet in room 215 and damaged wall in janitor room near A hall. Missing HVAC vent cover on ceiling in laundry room. 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 room 218. Keep all toilet equipment 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 and other patient items stored in spa room side and in room 218. Toilet rooms shall not be used for storage. See rule .1312 (b).

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Nov 25, 2019 94.5 / 100 · 5 violations

Inspector comments: No points deducted: #2--Observed black residue in grout in shower in spa on 200 hall. #9--Observed walker and wheelchair stored in restroom in 224. #32-Observed damage on corner of closet door in 212.

#3 · Walls and ceilings cleanable, clean, good repair −1

Observed holes in wall and peeling wall paint near window in activities room. Observed wall damage at can wash in janitor's closet on 200 hall. Observed wall damage in 224 restroom.

#8 · Facilities conveniently located, clean and in good repair −2

Observed residue on bottom of toilet chair in 203, 222, and underneath shower chair in 200 hall spa. Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).

#18 · Drinking utensils properly handled −1

Label water pitchers (gray) in resident rooms. Label all disposable water pitchers with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a).

#33 · Linen changed when soiled. Soiled linen handled properly −1

Observed stained sheets in 214 and 224 (including pillow case). Observed crumbs between sheets in 203. 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 stained straps on wheelchair cushion in 115. Observed box of cups stored on floor in med room in 200 hall. Observed bags of resident clothes stored on floor in 109. Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).

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Mar 13, 2019 90 / 100 · 9 violations

Inspector comments: NO POINTS: #12: Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). Observed no paper towels in 1 soiled utility room #17: Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a). Observed 2 fountains need cleaning in and around nozzles

#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 spa room shower stalls with black grout. Clean these areas better. Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b) Observed several pitted areas around handsinks. Many handsinks need better cleaning in staff areas. Replace broken or missing splash guards. Keep clean items out of splash zone of hand sinks Handwashing sinks shall be accessible to all areas where personnel may be exposed to bodily excretions or secretions. 15A NCAC 18A .1312 (d). Observed blocked hand sinks in 2 soiled utility rooms. Keep sinks accessible. 2 hand sinks contained garbage cans and dirty bowl/utensils.

#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). In shower rooms disinfectant using was Vital Oxide. Labeling stated it was a food contact surface sanitizer with a 9:1 dilution. Documentation located said to be used as a disinfectant there should be a 5:1 water to product ratio. Make sure the dispensing machine is calibrated for the correct ratio, get proper labels and train staff on importance of contact time as your kill step.

#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 preventer on shower wand in spa room. Observed no air gap between discharge pipes and trough for washing machines.

#22 · Solid waste disposed of frequently, no insect breeding or nuisance −1

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). Observed dumpster without drainplug. Get rid of old items stacked around shed. Many have been there for quite some time and are holding stagnant water.

#28 · Adequate storage, area clean, items properly stored −0.5

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 a couple of storage rooms where misc. items were dumped in there. Clean and organize all non-resident areas. Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a). Observed microwave and other PT items stored under hand sink in PT area.

#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 lips exposed on drinking cups on med carts. Protect cups from contamination

#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1

Laundry areas and equipment shall be kept clean. 15A NCAC 18A .1319 (b) and .1312 (a). Observed laundry area needs cleaning. Folding tables with personal items that hadn't been moved or cleaned around in some time. Several carts with dust/debris.

#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 rollers and other beauty shop items need cleaning including chair backs. PT bench with tear. PT area had no disinfectant available.

#36 · Approved utensils and equipment, cleaned and sanitized −1

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). Observed cabinets and shelves in nourishment room need cleaning

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Dec 17, 2018 85 / 100 · 11 violations

Inspector comments: NO POINTS WERE TAKEN FOR THE FOLLOWING: #2 - Observed floor tile in restroom of room 111 in need of cleaning. **Keep all flooring clean. 15A NCAC 18A .1309 (a). #5 - Observed cleaning needed on the AC unit in room 206, 118, and 216. Observed dust build-up on bathroom ceilig vents in several rooms. #14 - Observed housekeeping manager state that sharred bathing equipment in spa bathrooms are disinfected at the end of each day. **Skin contact surfaces of all shared bathing equipment shall be cleaned with a detergent solution and then disinfected with an EPA registered hospital disinfectant between patient uses. 15A NCAC 18A .1312 (f). #18 - Observed water cups without labeling in rooms on 100 hallway. **Label all disposable water pitchers with the resident’s/patient’s first name and last name. 15A NCAC 18A .1314 (a) #26 - Observed four trash cans being stored by the dumpster, filled with water without lids.**There shall be no fly or mosquito breeding places, rodent harborages, or undrained areas on the premises. 15A NCAC 18A .1317 (c). #33 - Observed soiled linen cart without labeling in the 200 hall soiled linen room. Observed stained sheet in room 206. Observed used towels and wash cloths being stored in restrooms of rooms 216 and 114. **Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b). **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). #34 - Facility washes common linen from different residents together. EHS did not see chlorine hooked up to washing machines. Facility was unable to provide documentation for sanitization. Facility did not have any documentation stating how hot water gets. See rule as follows: If hot water is used, linen including sheets, pillow cases, absorbent pads, towels and wash cloths provided by the facility shall be washed with a detergent in water at least 71°C (160°F) for 25 minutes. If low temperature (less than 71° C) laundry cycles are used, linens shall be washed in at least 50 parts per million chlorine or an EPA Listed laundry sanitizer shall be used in accordance with the manufacturer's instructions. **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 clean blanket being stored in spa restroom of 100 hall. Observed clean linen in laundry room to not be covered. **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).

#3 · Walls and ceilings cleanable, clean, good repair −1

Repeat Observed wall damage in room 216. Observed touch-up paint needed in various areas of hallways. Observed ceilings with dust build-up around vents in nourishment rooms. **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 Observed re-caulking needed on backsplashes of several hand sink areas of nourishment and soiled linen rooms. Observed cleaning needed on toilet chair in restroom of 216. Observed grout with heavy build-up in shower area of spa bathrooms. EHS used alcohol swab to remove build-up. Observed two shower chairs with feces on the seat in spa bathroom of 100 hallway. Observed tile cracked on corner of shower area in spa bathroom of 100 hallway. Observed toilet chair with damage to metal in room 111. Observed cleaning needed in toilet bowl of 114. Observed hand sink faucet with build-up and pitting in 114. **Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).

#9 · Toilet rooms free of storage, hand wash signs posted −0.5

Repeat Observed reclining chair being stored in spa restroom of 100 hall. **Toilet rooms shall not be used for storage. See rule .1312 (b).

#12 · Lavatories have mixing faucet or tempered water, soap hand towel and hand drying device −1.5

Repeat Observed paper towel dispensers with low battery, not dispensing in beauty salon and clean supply of 200 hall. **Provide liquid soap and disposable towels at all hand washing sinks. 15A NCAC 18A .1312 (d).

#19 · Ice protected, dispensed, equipment clean in good repair −1

Repeat Observed ice machine deflector plate with build-up in nourishment room of 200 hall and ice/water dispenser with heavy build-up in the 100 hall nourishment 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).

#22 · Solid waste disposed of frequently, no insect breeding or nuisance −2

Repeat Observed garbage collecting around dumpster area in need of clean-up. Observed dumpster doors open and drain plug missing from dumpster. **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). **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 · Furniture clean and in good repair. Mattresses clean, dry, odor free −2

Repeat Observed pillows with rips in clean linen closet of 200 hallway and room 216. Observed window curtains soiled in room 206. Observed window curtain with heavy staining in rooms 216 and 118. Observed debris on mattress that had been made up with bed in room 216. Observed stain on couch in resident living room. Observed laminate missing on closet drawers and doors in rooms 216 and 206. **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 −1

Repeat Observed rips on physical therapy table. Observed hair left in brushes and curlers in beauty salon. **Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).

#36 · Approved utensils and equipment, cleaned and sanitized −1

Repeat Observed nurse state that water pitchers are cleaned each shift in the nourishment room. Nourishment rooms only have one hand washing sink. Water pitchers are not to be cleaned in this area. Water pitchers are to be sent back to kitchen to be properly cleaned and sanitized. Observed microwaves in need of cleaning in nourishment rooms on 100 and 200 hallway. Observed cleaning needed in refrigerator and freezer of 100 hall nourishment room. Observed cleaning needed on the interior and exterior of cabinets in nourishment rooms. **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). **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).

#40 · Food brought by employees or visitors handled properly −1

Repeat Observed food items brought from home without labeling in 100 nourishment refrigerator and food items without dates in 200 hall nourishment refrigerator. **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).

#42 · Food protected. Potentially hazardous food maintained at 45 F or below, or 140 F for above, consumed or discarded within 2 hours of being removed from temperature control −2

Observed thermometer reading 50F in 200 hall nourishment room refrigerator. EHS took temperature of milk being stored in door which measured 50F. Juice being stored farther in refrigerator measured 48F. Management was aware of the refrigerator being at high temperatures. All food voluntarily discarded. Do not store food/drink in this refrigerator until it is capable of holding foods at 45F or below at all times. **All potentially hazardous food products shall be maintained at 45°F, or below, or 140°F or above except during necessary periods of preparation and serving. 15A NCAC 18A .1323 (a).

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Apr 27, 2018 90 / 100 · 9 violations

Inspector comments: No Points Deducted: 14. 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). 19. Observed pink builup in the ice chute on 200 hall- nourishment 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). 30. Observed buildup inside of a med cart drawer. Clean. Also, a cloth towel was present lining the bottom of a drawer in a med cart. Remove. Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c). **NOTE: Observed 1 glucometer on a med cart. Inspector asked a Med Tech about how she uses and cleans it. Her response was "I do not know the policy of how it is done here." ENSURE THAT ALL EMPLOYEES KNOW PROCESSES AND RULES OF HOW TO CLEAN/USE ALL THINGS THAT THEY ARE ACTUALLY USING/DOING. Wipes were found in therapy that are used to clean the glucometer between each resident.

#3 · Walls and ceilings cleanable, clean, good repair −1

Repeat: Observed some damaged walls in rooms. (Points not increased). 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: Observed loose toilet seats in 209, 226, and the whole toilet moving in 117. *Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). -Observed black grout in both of the shower rooms. Inspector used an alcohol wipe and some of the black buildup came off. -Observed buildup on shower curtains in the shower rooms. Clean. Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). -Observed pink buildup around the drain, handles, and backsplash of the sink in 200 hall supply room. Clean. 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

Repeat: Observed wheelchairs and geriatric chair trays stored in the shower room. Toilet rooms shall not be used for storage. See rule .1312 (b).

#12 · Lavatories have mixing faucet or tempered water, soap hand towel and hand drying device −1.5

Observed no soap or paper towels in 200 hall med room, nourishment room, room 220, and the beauty salon. Provide. Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d).

#22 · Solid waste disposed of frequently, no insect breeding or nuisance −1

-Repeat: Observed bags of garbage on the ground behind the dumpster. -Observed the dumpster open, rusted, bent, and with a hole in the back. -Observed a construction dumpster onsite with "resident" trash in it. DO NOT STORE ANYTHING BUT CONSTRUCTION/FURNITURE AND OTHER THINGS OF THAT SORT IN THE CONSTRUCTION DUMPSTER. 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).

#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −2

Repeats: -Observed raw wood exposed on headboards and footboards throughout facility in resident's room. Refurbish furnishings in resident's rooms. -Observed a hole in a pillow in the therapy room. -Observed stains and debris on and under the couch cushion in the common room. -Observed stains on pillow, debris on mattress, and stains on the dividing curtain in 209. -Observed laminate on closet drawers missing. Paint or seal exposed raw wood. 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 −1

Repeat: -Observed tear on physical therapy table. -Observed hair rollers in salon that still contained hair from previous patient. Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).

#36 · Approved utensils and equipment, cleaned and sanitized −1

-Observed buildup inside of the microwaves in activity and nourishment rooms. Clean. -Observed buildup in the drawers in the nourishment rooms. Clean. -Observed blue coolers with pink buildup and debris in the 200 hall nourishment room. Clean. 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).

#40 · Food brought by employees or visitors handled properly −1

Repeat: Observed outside food in the nourishment refrigerator 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).

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Jul 17, 2017 94 / 100 · 6 violations

Inspector comments: No points deducted: 5. Observed minor dust build up on vents throughout and minor dust on ventilation in two rooms. Overall improvement from last inspection. Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). 9. Observed geriatrics chair stored on common restroom on 200 hallway. Toilet rooms shall not be used for storage. See rule .1312 (b). 19. Observed ice scoop stored in container that had minor black build-up. Scoop was taken to the kitchen to be cleaned. 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). 22. Observed minor debris in dumpster area that needs to be cleaned. Overall improvement from the last inspection. 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). 28. Observed a few small boxes on the floor in the medication room that appeared to have fallen off of shelving. Relocated to proper storage. All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). 30. Observed box of kleenex stored on top of sharps container on two medication carts. Informed nurse on proper storage of tissue away from sharps container. Tissue was relocated. Inspection led by Jamil Blackmon REHSI

#3 · Walls and ceilings cleanable, clean, good repair −1

Observed some damaged walls behind headboard in rooms 220, 216, 117 and 121. Improvement from previous inspection. 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 pitted faucet fixtures in two rooms. Observed missing grout in common bath area on both 100 and 200 hallway. Observed broken tile on wall baseboard in bath area on 100 hallway. Observed loose tile in shower in common bath area on 200 hallway. Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).

#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1

Observed minor damage to headboards and footboards throughout facility in resident's room. Refurbish furnishings in resident's rooms. Observed separation curtains with stains in room 114. Observed bands on closet doors that were coming undone and laminate separating. Needs to be repaired. Observed broken blinds in private treatment 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 tear on physical therapy table and balance pad that needs to be replaced. Observed stained padding in wheelchair in rehabilitation room, needs to be thoroughly cleaned. Observed hair rollers in salon that still contained hair from previous patient. Observed torn pillows in rooms 220, 109 and 104. Pillows were removed and discarded. Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).

#39 · Food supply complies with 15A NCAC 18A .2600 −2

Observed prepared sandwiches in refrigerator in nutrition site that were beyond the discard date of 7/10. Out of date sandwiches were discarded by operator. All food and food supplies provided by an institution shall be from sources that comply with 15A NCAC 18A. 2600.

#40 · Food brought by employees or visitors handled properly −0.5

Observed hinged tray of food in refrigerator on 200 hallway and food in refrigerator on 100 hallway that were not labeled with a name or a date. 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).

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Jan 31, 2017 85.5 / 100 · 12 violations

Inspector comments: No Point Deductions/ General Comments: #9. Observed jerry chairs stored in common bath/shower. Do not use bathrooms for storage. Remove jerry chairs from bathrooms.****Toilet rooms shall not be used for storage. See rule .1312 (b). #17. Observed missing face plate on drinking water fountain. Fix face plate on water fountain.***Drinking fountains shall be kept clean, good repair and properly regulated. 15A NCAC 18A .1314 (a). Inspection led by Tim Gentry and accompanied by Shawn Blackmon. Precious Ayiyi and Gary Krupa present at time of inspection.

#1 · Floors easy to clean, no obstacles, drains where needed −1

Observed damaged floors in residents rooms in front of air conditioning and heating units and therapy room. Repair base tile cove molding and general cleaning of floor in 200 hall shower room. Thoroughly clean floors in residents rooms behind doors. Thoroughly clean floors throughout in hallway and storage rooms! Observed floors soiled throughout in areas. Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b).

#3 · Walls and ceilings cleanable, clean, good repair −2

Observed damage to walls in resident rooms throughout behind beds and next to heating and cooling units in rooms. Observed questionable fecal matter on walls near hand railings and emergency call buttons in bathrooms. THOROUGHLY CLEAN WALLS THROUGHOUT FACILITY IN BATHROOMS AND RESIDENTS ROOMS. Clean debris from behind handrails and the handrails also. Thoroughly clean, repair and repaint front entrance door and foyer door. Repair damaged wall paper in hallway on 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 debris present in top of heating and cooling units in residents rooms. Thoroughly clean debris from top of heating and cooling units. Observed dust build up on ventilation in bathrooms within residents room. Thoroughly clean vents in bathrooms. 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 fecal matter on of toilet chair (top and underside) and urine stains on toilet seat in several patients bathrooms; throughout clean bathroom/toilet fixtures. Observed pitted faucet fixtures on hand washing sinks throughout in resident bathrooms within room and common bath/showers. Replace pitted faucet fixtures on hand washing sinks. Observed hand washing sinks obstructed with storage in front of sink and storage too close to hand washing sinks(cross contamination). DO NOT OBSTRUCT OR BLOCK HAND WASHING SINKS! Recommend keeping an eighteen inch clearance around hand washing sinks! 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 −1

Observed Unlabeled bedpans and emesis basin in room 204. Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c). -Hopper in both soiled utilities rooms blocked and unaccessible. Clean out room to provide a clear path to hoppers for the proper disposal of waste and proper cleaning of bedpans. Observed items stored on top of hopper. Do not store or place items on top of hopper.

#19 · Ice protected, dispensed, equipment clean in good repair −1

Observed build up of pink debris on chute of ice machine in nutrition room. Observed stagnated water with microbial growth in the base of ice scoop holder in nutrition room. Thoroughly clean exterior of ice cooler chest. 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).

#22 · Solid waste disposed of frequently, no insect breeding or nuisance −1

Observed bed frame, mattresses, broken wheelchairs and pallets stored behind the building and in dumpster corral. Remove pallets, mattresses and bed frame from premises. Observed open doors on dumpster. Observed can wash drain clogged/blocked, located out back door. Repair drain in can wash so mop water does not drain out onto the grass area. 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).

#28 · Adequate storage, area clean, items properly stored −1

Observed storage of patient contact items stored on the floor throughout facility in storage rooms. Observed package of briefs in spa tub in common shower/bath. Observed linen stored on spa tub in common bath/shower. Do not store or place brief or clean linen in or on spa bath. All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).

#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −2

Observed single use cups stored improperly throughout the facility on medication carts. Cover drinking utensils while being stored on carts Observed base of drawers and pill crushers on med carts soiled. Thoroughly clean base of drawers on med carts and pill crushers! Unused medication cups shall be kept covered or inverted. 15A NCAC 18A .1318 (c). 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 −2

Observed fall pad visibly soiled with blood. Observed cabinet doors visibly soiled with blood. Observed broken hinges on cabinets throughout the facility in residents rooms. Observed stained chairs throughout facility in residents rooms. Thoroughly clean all furniture throughout the facility on a regular basis. Thoroughly clean curtains on windows and separating beds. Replace missing laminate/bands on furniture/fixture or paint exposed wood where bands/laminate is missing. Observed paint/stain worn from foot boards and head boards on resident beds. Refurbish or replace footboards and head boards in resident rooms. Observed over bed tables soiled in resident rooms. Thoroughly clean over bed tables. 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

Observed sheets visibly soiled with blood on patients bed in room 224. Observed sheets visibly soiled with questionable fecal matter on patients bed in room 204. These "clean" bed were made by CNA's. HAVE WHOEVER IS MAKING THE BEDS TO PULL ANY SOILED SHEETS, FITTED SHEETS, SPREADS,ETC. 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 jerry chair. Replace damaged arm rest on jerry chair. Observed package of briefs in spa tub in common shower/bath. Observed linen stored on spa tub in common bath/shower. Do not store or place brief or clean linen in or on spa bath. Observed torn/damaged bed spread on resident bed. Discard any torn/damaged linen in residents room. Repair padding on therapy table. Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).

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Jun 29, 2016 90.5 / 100 · 8 violations

Inspector comments: No Points Deducted Today: 8. Observed the shower stretcher pad torn in the 100 hall spa. Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). 16. Observed an incomplete backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f). *The Checklist Handout was emailed to Dennis Carver. 21. Observed the dumpsters leaking. One is missing a drain plug, and the other has a hole in the side. Replace. 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). Ms. Ruby Hayward present during the inspection.

#3 · Walls and ceilings cleanable, clean, good repair −1

Repeats: -Observed walls throughout facility in hallway, residents room, resident bathroom and storage room in need of touch-up paint. -Observed wallpaper peeling on the 100 hall. -Observed baseboards either off or loose in several rooms. 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

-Repeat: Observed bedpans and urinals not properly labeled throughout in resident rooms. Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c). -Per CNAs, the bedpans and urinals are cleaned in the restroom sink. Follow the rule below. -Also, the hoppers in the soiled utility rooms are blocked. Remove all items so that there is a clear path to and from the hopper. Where facilities for cleaning bedpans 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 cleaner 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). -Observed a therapist use a patient's personal shower chair in the spa and begin to take it back to his room without cleaning it. Never transfer soiled shower equipment through the halls. -A CNA stated that she usually sprays the shower equipment and wipes it down. Follow the manufacturer's directions. The manufacturer's instructions shall be followed for cleaning equipment with pumps. See rule .1312 (f). Skin contact surfaces of all shared bathing equipment shall be cleaned with a detergent solution and then disinfected with an EPA registered hospital disinfectant between patient uses. 15A NCAC 18A .1312.

#28 · Adequate storage, area clean, items properly stored −0.5

Observed boxes of briefs, cups, etc stored on the floor in rooms and in storage rooms. All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).

#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −2

Repeats: -Observed the drawers of the med carts with heavy residue and buildup. Clean. Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c). -Observed the mouthpieces of the drinking cups on the med carts exposed. Store all items to prevent contamination. 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 −2

Repeats: -Observed the bed head and foot boards peeling and/or in disrepair on the resident's beds throughout facility. -Observed the closet door in disrepair and the bar under the tv in room 122 in disrepair. 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).

#36 · Approved utensils and equipment, cleaned and sanitized −1

-Observed the microwaves and cabinet drawers (inside and out) in the nourishment rooms soiled- 200 hall. Clean. 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).

#40 · Food brought by employees or visitors handled properly −1

Repeat: Observed some food not labeled in the nourishment refrigerators and some with dates of 6/7/16. Ensure all is labeled. 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).

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Sep 25, 2015 91 / 100 · 9 violations

Inspector comments: General Comment: #1. Repair cracked floor tile in 100 common shower. Remove rug from bathroom area in 221 bathroom.**Floors shall be free of obstacles to cleaning. 15A NCAC 18A .1309 (a). #15. Observed back flow prevention devices missing from all shower wands in common baths/shower on both 100 and 200 hall. Provide back flow prevention devices on all shower wands in common bath/shower. Shower wands had been replaced.**Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d). #17. Observed water pressure on water fountain on 100 hall too high and water is splashing onto the floor. Lower water pressure on water fountain on 100 hall.**Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a). #19. Clean exterior of ice chute on ice dispenser in nourishment center on 100 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). #22. Remove old pallet, mattress, air . conditioner, old chair lift from dumpster area and beside storage building.**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). Lisa Rivers, Gary Krupa and Danute Nykas present at time of inspection.

#3 · Walls and ceilings cleanable, clean, good repair −1

Observed walls throughout facility in hallway, residents room, resident bathroom and storage room in need of touch-up paint. Touch-up paint throughout facility. Recommend sanding down front entrance door between lobby area and hallway area and repaint doors. Tightly secure and seal loose wall paper on 100 hall or just remove wall paper and repaint. Secure hand washing sink to wall in 212. Monitor ceiling in clean linen closet on 200 hall and ceiling in front of nourishment station on 100 hall and repair any roof leaks or wrap ventilation duct work. Tightly secure loose cove base moulding in 216 and 101. Repair wall behind bed in room 222 and lower section of wall in 121 and repaint. Clean window covering in room 224. Clean wall in room 122 beside bed A. Re-apply sealant/varnish on resident bathrooms doors which sealant/varnish is wearing off. Keep all walls and ceilings clean and in good repair. 15A NCC 18A .1310.

#5 · Ambient air temperature 65 to 85 F, equipment clean −1

Observed some light dust on ceiling ventilation in hallway, lobby area and bathrooms within resident room. Clean/dust ceiling ventilation. Observed debris present behind covering on heating and cooling unit. Remove covers from heating and cooling unit and clean debris from 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 −0.5

Observed bedpans and urinals not properly labeled throughout in resident rooms on both 100 and 200 halls. Label bedpans and urinals with residents name and date items were provided. Observed path to bedpan lug and spray arms obstructed in bio hazard closet. Keep pathway clear to bedpan lug and spray arms in bio hazard rooms so bedpans and urinals can be emptied, clean and disinfected in bio hazard rooms.Where bedpans are cleaned in patient/resident rooms, bedpan cleaning facilities shall consist of a water closet with bedpan lugs or spray arms. 15A NCAC 18A .1312 (c).Label all disposable bed pans and urinals with the residents/patients name and date. 15A NCAC 18A .1312 (c).

#23 · Medical wastes handled and disposed of properly −1

Observed sharps container over flowing with needles in med room on 200 hall. Close and replace sharps containers when full!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 cases of paper work stored on the floor in nurse training room storage room and beauty shop/storage room. Provide additional shelving or dunage rack to store items off the floor. Observed wheel chairs and jerry chairs stored outside of back door to facility. Store unused wheel chairs and jerry chairs in outside storage building. Provide an additional storage building if needed. 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 single service articles(pill cup and water cups) not properly stored on med carts. Observed pill crusher and base of drawers on med carts soiled. Store pill cups and water cups in a zip loc bag or enclosed plastic container. If storing in plastic container on top of carts; minimize the amount of cups placed in containers. THOROUGHLY CLEAN PILL CRUSHERS ON MED CARTS! Clean base of drawers on med carts. 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 foot boards and head boards on resident beds throughout facility. Repaint or restains night stands in resident rooms throughout where needed. Repair closet door in 212. Observed loose and missing laminate on closet door and closet fixtures in rooms. Tightly secure loose laminate on closet door/closet fixture, replace missing laminate or paint area where laminate is missing. Clean out night stand dresser drawer in room 122. Clean chair in room 105.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 damaged wheel chair seat on wheel chair in 200 hall common shower. Replace damaged seat in wheel chair or replace wheel chairs. Observed patient contact items(bandages, wound care items, gloves) not properly stored in resident rooms on television shelving between resident closet. Clean and organize area where patient contact items are stored. Observed bed wedges/bed items stored on the floor in storage rooms. Store patient contact items off the floor. Patient contact items shall be kept clean,in good repair and stored to prevent contamination. 15A NCAC 18A .1319 (c).

#40 · Food brought by employees or visitors handled properly −1

Observed food in nourishment refrigeration unit on 200 hall not properly labeled with name and date. Label resident food and employee food with name and date food was brought into facility. Observed employee food stored above medication in refrigeration unit in nurse training room. Do not store employee food products in med refrigeration unit. 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).

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Mar 19, 2015 93 / 100 · 7 violations

Inspector comments: General Comment: #10. Observed bed pan in room 211 bathroom not labeled or dated. **Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c). #1. Observed cracked/damaged floor tile at entrance to room 204 and in room 225. Replace damaged floor tile.**Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b). #35. Observed new mattresses in boxes behind facility. Store and place mattresses in storage shed/room to prevent items from getting wet. Mrs. Jamie Runkel and Mr. John Bridges present at time of inspection.

#3 · Walls and ceilings cleanable, clean, good repair −1

Observed lower section of wall throughout facility in rooms and bathrooms in need of painting. Continue to touch-up paint/repaint throughout facility where needed. Wipe/clean walls throughout where needed. Repair lower section of wall in room 204 bathroom, tightly secure rubber cove base moulding and repaint. Observed water stain on ceiling in nourishment room on 200 hall. Monitor spot on ceiling and repair any roof leaks and repair/repaint ceiling. Monitor ceiling around crown moulding and expansions joint and seal any gaps if needed. Observed some small gaps around crown moulding and expansion joint due to building settling. Observed some nail poppers on ceiling in hallway and resident rooms. Hammer in nails and touch-up paint ceiling where needed. Replace missing rubber cove base moulding near counter top in room 111. Repair wall in lower section of can wash in janitor closet and monitor and repair wall behind drain trough in laundry room. 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 minor dust on heating and cooling unit covers in rooms. Observed debris present behind heating and cooling unit covers throughout in several rooms. Remove covers/face plate on heating and cooling unit and clean top of units. Clean ceiling ventilation near hand washing sink in common bath/shower. Observed some accumulation of dust on fixture. Replace cracked cover on heating and cooling unit in room 119.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 underside of potty chair in room 211 soiled. Thoroughly clean underside of potty chair. Observed pitted faucet fixture on hand washing sink in room 225. Replace pitted faucet fixture on hand washing sink in 225 and anywhere else needed. Tightly secure and seal hand washing sink to wall in room 111 bathroom. Observed some leakage around hand washing sink handle valve stem in supply room/ soiled item room. Repair leaking valve stem on hand washing sink handles. 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)

#28 · Adequate storage, area clean, items properly stored −0.5

Observed storage on the floor in employee training room and storage room. Remove storage off the floor.All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).

#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −2

Observed single service articles(water cup and med cups) not properly stored on medication carts. Keep med cups and water cups covered/protected from contamination. Clean shelving area on med carts where cups are stored. Thoroughly clean pill crushers on medication carts. Wipe/clean base of drawers on medication carts. 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).

#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1

Observed loose and damaged laminate on edge of cabinet, drawer doors and kick plate on base of cabinets. Tightly secure loose laminate on cabinet and drawer doors. Where laminate is missing; I recommend painting bare wood area. Repair hinge on cabinet door in room 204. Observed some spots/stains on privacy curtains in rooms. Thoroughly clean privacy curtains or replace. Observed soiled fall mat in room 119. Observed some fall mats showing wear where mats is folded. Monitor area where fall mats are folded and replace if needed. Recommend not folding fall mats to prevent damaged at area where mats are folded. Observed some areas on furniture where sealant is worn/damaged. Recommend restaining/revarnishing areas on night stands and foot and head boards where sealant/varnish is worn off.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 food products stored in nurishment room refrigeration unit on 100 and 200 hall not properly labeled. Labeled resident food, employee food, activity food with a name and date food was brought into facility. Activity program food/drink label; facility activity and date when food was brought into center. 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).

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Sep 18, 2014 92.5 / 100 · 6 violations

Inspector comments: General Comment: #8.Continue to monitor for any pitting faucet fixtures on hand washing sink and replace if needed. Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)#17. Increase water pressure on water fountain on 200 hall near nurse station leading back toward laundry room. **Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a). Mrs. Jamie Runkel and Mr. John Bridges present at time of inspection.

#3 · Walls and ceilings cleanable, clean, good repair −1

Observed lower section of wall throughout facility in rooms and bathrooms in need of painting. Residents wheelchair's are rubbing lower section of wall. Replace missing rubber base cove moulding in room 111 along corner and behind residents bed. Observed loose edge of wall paper in hallway area. Facility is in the process of removing wall paper and painting wall throughout entire facility.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 ventilation and ventilation covers soiled throughout in residents room. Thoroughly clean ventilation and ventilation covers.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 waste hopper and hand washing sink obstructed by trash cans and soiled linen bins in bio hazard waste room. Do not block or obstruct hand washing sink and waste hopper in bio hazard room.Toilet, hand washing, and bathing facilities must be conveniently located and readily accessible to residents and staff. 15A NCAC 18A .1312 (a).

#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −2

Observed base of drawer on medication cart and pill crusher on med carts soiled. Thoroughly clean pill crusher and base of drawers on med carts. Observed cold holding containers on medication carts soiled. Thoroughly clean cold holding containers used on med carts.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 −2

Observed stains on some chairs throughout facility, missing laminate on closet doors/drawers, damaged/soiled fall mats, night stains with exposed pressed board/wood, damaged over bed table and food board on bed in need of staining. Clean stains on chairs. Replace missing laminate on closet door/drawer or paint area where laminate is missing. Thoroughly clean fall mats and replace damaged ones. Stain night stand and foot board on bed where press wood is exposed. Repair or replace damaged over bed tables.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 diapers stored on the floor in med room and resident room. Store diapers on shelving in med room and residents room. Observed hole in linen on residents bed. Continue to monitor and discard any damaged linen.Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).

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Jun 5, 2014 90.5 / 100 · 9 violations

Inspector comments: Mr. John Bridges present during inspection.GC #34: Maintain records for maintenance on washing machines and the amount of sanitizer (ppm's) for each cycle.**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). GC #21: Observed broken drain plug in dumpster and doors open.**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).

#3 · Walls and ceilings cleanable, clean, good repair −1

Observed stained ceiling in 200 hallway. Wall damage in laundry room and several bedrooms behind beds. Wall damage in bathroom, room**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 corroded faucets in 100 hall nurse's bathroom and laundry room. Grouting black in showers both shower rooms. Soiled/stained toilet and toilet seat 100 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 handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)

#14 · Disinfectant accessible, properly used −1

| Observed no disinfectant available in 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).

#17 · Water fountains clean, good repair, properly regulated −1

Observed water fountain with water pressure too low.**Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a).

#19 · Ice protected, dispensed, equipment clean in good repair −1

Observed ice and water dispensers in nourishment rooms with residue build-up around nozzles/chutes.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).

#28 · Adequate storage, area clean, items properly stored −0.5

Observed single service cups stored below hand sink, 100 hall nourishment room.**Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a).

#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −2

Observed pill crushers on med carts 100 and 200 hall with build-up. Cup of coffee on top of 200 hall cart. Straw and rag on sharps container,100 hall med cart.NOTE: Both med carts were unattended and unlocked.**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 tears in bottom of mattress, room 101. Frayed fall mat, room 109.**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

Observed soiled linens thrown into tub, 100 hall shower room. Holes in sheet and soiled sheet, room 109. torn pillows in rooms 109 and 101. **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).**Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).

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Aug 8, 2013 91.5 / 100 · 6 violations

Inspector comments: Mr. John Bridges, Mr. David Poe, and Erica Yocum present during inspection.**Keep sharps containers away from paper towel dispensers. Don't want towels to touch sharps containers when dispensing.**Make sure pet vaccination records are up to date.**Keep ice chutes clean, CDI.

#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −0.5

Observed urinals not labeled with name and date, rooms 211, 222, and . Observedrusty toilet chairs in rooms 119, 109. Observed soiled utility room with hopper inaccessible without moving several items.15A NCAC 18A .1312 TOILET: HANDWASHING: LAUNDRY: AND BATHING FACILITIESWhere facilities for cleaning bedpans 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. Where disposable bedpans are reused, they shall be labeled with the patient's name and date and shall not be used by more than one patient.

#11 · Hand sinks used only for intended purpose −2

Repeat Non-Compliance: Observed employee drinks in hand sink, nourishment room.15A NCAC 18A .1312 TOILET: HANDWASHING: LAUNDRY: AND BATHING FACILITIESHandwash lavatories shall be used only for handwashing.

#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −2

Repeat non-Compliance: Observed Kleenex stored on sharps container, med cart. Observed single service spoons stored with handles down, med cart. Single service cups and pill cups unprotected on med carts. Observed med pass on med cart not labeled with time, if not kept under temperature control med pass must be disposed of in 6 hours (per distributor).15A NCAC 18A .1318 MISCELLANEOUSFood and utensils used on medication carts shall be handled in a sanitary manner.

#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1

Observed hole in mattress cover, room 101. Pillows torn, room 109. Soiled mattress bolster, room119. Fall mats soiled and or frayed in several rooms. Mattress cover fraying, room 211.15A NCAC 18A .1319 FURNISHINGS AND PATIENT CONTACT ITEMS(a) 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.

#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −2

Observed clean linen carts in laundry room with debris. Spills on shelving on several clean linen carts. Several clean linen cart covers frayed or torn.15A NCAC 18A .1319 FURNISHINGS AND PATIENT CONTACT ITEMSClean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. Laundry areas and equipment shall be kept clean.

#40 · Food brought by employees or visitors handled properly −1

Observed employee drinks unlabeled, nourishment room. Observed opened juice not dated, nourishment room.15A NCAC 18A .1321 FOOD SUPPLIES(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 foodwas brought in and shall be kept only as long as it is clean, and free from spoilage.

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Source: Mecklenburg County Public Health – Environmental Health public inspection portal (search for “MECKLENBURG HEALTH & REHABILITATION” or State ID 2060400037). Inspection type (routine vs. follow-up) is not published in the county's data.