97/ 100
WILORA LAKE HEALTHCARE CENTER
6001 WILORA LAKE RD, Charlotte, NC 28212
Rest/Nursing Homes · NC permit/State ID 2060400042
Latest result97 / 100
Last inspectedJun 10, 2026
Inspections on record23
On record sinceDec 30, 2013
Score history
Dec 30, 2013Higher is betterJun 10, 2026
Inspections & violations
Jun 10, 2026 97 / 100 · 6 violations
Inspector comments: *NOTE: Executive Director, Cynthia Pittmon, signed for report. Report emailed to the following: Cynthia.D.Pittmon@WiloraLake.com
#2 · Walls and ceilings clean, good repair −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 some floor tiles 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. Observed minor wall damage throughout facility and touch up paint needed. Major improvement has been made since previous inspection report. Observed wall damage in shower room on 100 hallway.
#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 wheelchairs stored in shared spa room on 100 hallway. Improvement from previous inspection report.
#10 · Handwashing facilities properly located and equipped
.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices. Observed no disposable towels at handsink in shared spa room on 100 hallway. Disposable towels were supplied to handsink during time of inspection. -General comment.
#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 incomplete back up water supply plan. EHS emailed administrator template for creating back up water supply plan that is in accordance with notated rule. -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.
.1314 (c) Ice machines and storage chests accessible to residents, guests, or the public shall provide ice through automatic ice dispensing equipment and shall not permit ice to be accessed using a scoop or bucket.
Observed ice chests throughout facility left unattended and unlocked. EHS advises center to adhere to notate rule.
REPEAT VIOLATION.
#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 vinyl pillow case with tears in room 103. Discard. Observed debris on mattress in room 406. Clean.
Nov 21, 2025 96 / 100 · 6 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free
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 minor floor damage in laundry room. -General comment.
#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 walling damage behind beds in rooms 201 and 402. Observed touch up paint needed to door frames and walling throughout. REPEAT VIOLATION.
#5 · Ventilation equipment clean, good repair −0.5
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed dust accumulation to removable vents in rooms 111 and 311. Clean. REPEAT VIOLATION.
#8 · Toilet rooms free of storage, handwash signs posted −1
.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed all shower rooms within facility containing storage not used for toileting to include clothing, wheelchairs, and rolling bins for soiled linen/trash. REPEAT VIOLATION.
#20 · Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair
.1314 (c) Ice shall be protected against physical, chemical, and biological contamination and shall be kept clean. Observed ice chest on 300 hallway stored unlocked and unattended. -General comment.
#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 nourishment room refrigerators containing outside food not properly labeled according to notated rule on hallways 300 and 400.
Jun 25, 2025 96.5 / 100 · 6 violations
#2 · Walls and ceilings clean, good repair −2
Observed wall damage in the laundry room. Observed touch up paint needed in room 407. Observed ceiling leaking on the 400 hall. Observed wall in the shower rooms 100 and 200 in need of 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.
#5 · Ventilation equipment clean, good repair −0.5
Observed vent filter in need of cleaning in rooms 407 and 402.
**.1311 (b) Ventilation equipment shall be kept clean and in good repair.
#7 · Facilities provided, accessible, clean, good repair
Observed shower curtain in need of cleaning in the shower room on 400 hall. Needs to be cleaned.
**.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 −0.5
Observed wheelchairs stored in the shower room on 200 hallway.
**.1312 (b) Bathrooms shall not be used for storage of items not currently in use.
#9 · Bedpans, urinals, bedside commodes and emesis basins properly cleaned and disinfected
Observed bedside commode in need of cleaning in room 206. Room is currently unoccupied. Bedside commode was emptied.
**.1312 (c) Institutions where bedpans, bedside commodes, urinals, or emesis basins are used shall provide facilities for emptying, cleaning, and disinfecting bedpans, bedside commodes, urinals, and emesis basins.
#38 · Food service equipment and utensils clean, good repair −0.5
Observed refrigerator gasket in need of repair and crisper drawer full of water on 400 hall.
**.1320 (a) All food service equipment and utensils shall be kept clean and in good repair.
Dec 10, 2024 97.5 / 100 · 2 violations
#2 · Walls and ceilings clean, good repair −2
Observed wall damage in the laundry room, activity room, bathing spa on 400, 300 and 100 hall, rooms 410 and 403.
**.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair −0.5
Observed stained divider curtain in room 402. Observed cushion stained in room 410.
**.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.
Jun 5, 2024 97 / 100 · 4 violations
#2 · Walls and ceilings clean, good repair −2
Observed touch up paint needed in laundry room. Observed baseboard tile in need of repair in the spa on 300 and 100 hall. Observed wall damage in room 110. Observed ceiling damage in room 303.
**.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair.
#16 · Hot water between 105°F and 116°F
Observed water temperature at 118F in the spa on 300 hall and 119F in activity room.
**.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.
#20 · Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair −1
Observed ice chest on the main hallway left unattended and accessible.
**.1314 (c) Ice machines and storage chests accessible to residents, guests, or the public shall provide ice through automatic ice dispensing equipment and shall not permit ice to be accessed using a scoop or bucket.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair
Observed torn pillow in room 306. Removed.
**.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.
Dec 14, 2023 96 / 100 · 4 violations
#2 · Walls and ceilings clean, good repair −2
Observed wall damage throughout facility. Observed ceiling in need of painting in the main living room. Observed ceiling damage in memory care. Observed door frame in need of repair in room 410.
**.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 tile in need of repair near the shower in the bathing suite.
**.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
Observed wheel chair foot rails stored in the bathing suite. Foot rails were removed during the inspection.
**.1312 (b) Bathrooms shall not be used for storage of items not currently in use.
#20 · Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair −1
Observed ice chest on the 100 hallway left unattended and accessible.
**.1314 (c) Ice machines and storage chests accessible to residents, guests, or the public shall provide ice through automatic ice dispensing equipment and shall not permit ice to be accessed using a scoop or bucket.
May 12, 2023 94 / 100 · 10 violations
Inspector comments: NO PPOINT DEDUCTION FOLLOWING ITEMS:
#16. .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 temperature in 400 hall at 102F - 103F. Provide water temperature at least 105F and not exceed 116F.
#10. .1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices. Observed no paper towel at hand sink in therapy room, 405, and women restroom at the front entrance. Ensure to provide all hand washing supplies at all hand sink at all time.
#. Observed electric wheelchair stored in 200 hall bath. Remove the wheelchair and only store bathing equipment only.
#. Observed therapy equipment are blocking the hand sink in the therapy room. Equipment removed at the time of inspection. Ensure to clear a path for hand washing accessibility at all time.
NOTE: Mr. Leon Terrell and Ms. Pam present during inspection.
#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 major damaged ceiling from a big leaks in the activity room in Main hall, ceiling was covered with a big plastic to prevent the residue from falling. Staining and peeling popcorn ceiling throughout hallways. Repair, repaint needed and keep all in good repair. Observed scraping walls and doors, possibly need repair, repaint as it fits.
#7 · Facilities provided, accessible, clean, good repair −1
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed loose or damaged toilet seat in room 308, 200 and 300 hall bath, Need repair or replace. Observed toilet in rooms on 300 and 100 hallway can receive better cleaning. And keep clean. Observed in all baths, shower floor trim need caulking, damaged tiles along the base in 200 hall bath. Need 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 posted in therapy and 100 hall restrooms, any other restrooms have the sign posted. Hand washing signs need to be posted. Hand washing signs provided at the time of inspection.
#11 · EPA registered disinfectants used according to manufacturers' instructions; approved testing methods and devices used −1
.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. Observed housekeeper cleaning a room and when asked how to clean effectively using chemical (contact time and what type of chemicals use), a housekeeper doesn’t seems to have knowledge on how to effectively clean surfaces per manufacturer’s instruction. The facility need to ensure that all staff/cleaning staff have a knowledge of how to use chemical and clean effectively according to manufacturer's instructions.
#18 · Drinking fountains clean, good repair −0.5
.1314 (a) Drinking fountains shall be kept clean and in good repair. Observed water fountains throughout the facility are in need of deep cleaning and keep clean. The facility is not using the fountains currently, however they shall be kept clean.
#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 on every hall left unattended and not protected. There is a nourishment room in every hall. ICE SHALL BE PROTECTED AT ALL TIME.
#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 frayed mattress at the corners, damaged, stain mattresses in some rooms throughout the facility. Observed damaged sink cabinets/trim in Main hall nourishment room. Need repair or replace.
#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 heavy food debris in microwaves in nourishment room in Main, 400 hall. Need deep cleaning and keep clean.
#51 · Proper use of restriction, exclusion, and reporting
.1324 (c) Institution employees shall comply with the requirements for exclusion from work and restriction due to communicable disease or illness required for food employees as set forth in Parts 2-201.12 and 2-201.13 of the Food Code incorporated by reference at 15A NCAC 18A .2650 as amended by 15A NCAC 18A .2652. NEW RULE. NO POINTS DEDUCTION. Employee Health Policy discuss with staff and EHP poster provided at the time of inspection.
#52 · Vomitus and diarrheal clean up supplies; written clean up procedures available and complete
.1324 (d) The institution shall have gloves, personal protective equipment, disinfectant, individual disposable towels, and a coagulating agent on-site for employees to use and a written procedure for employees to follow when responding to vomitus or fecal matter on institution surfaces. The procedure shall specify the actions that employees shall take to minimize the exposure of employees, residents, guests, food, and additional surfaces to vomitus or fecal matter. NEW RULE. NO POINT DEDUCTION. The facility need to obtain the vomiting and diarrhea kit along with instructional plan how to clean up in such an event. Vomit or diarrhea clean up procedures poster provided at the time of inspection.
Nov 30, 2022 95 / 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 ice stored unattended and unlocked on 100 hallway.
#36. 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 detailed cleaning needed to refrigerator/freezer in memory care nourishment room.
*NOTE: Head of maintenance, Leon Terrell, and head of housekeeping, Pam, were present during time of inspection. Report emailed to:
leon.terrell@consulatehc.com
#3 · Walls and ceilings cleanable, clean, good repair −2
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed popcorn ceiling peeling sporadically throughout building. Observed wall tiles and floor tiles damaged in shared spa rooms. Observed touch up paint needed to wall joints and baseboards throughout building.
#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 in shared spa rooms to include furniture and large rolling bins.
#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 stored not inverted or covered on medication cart stored on 200 hallway.
#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 flooring to cabinet in activity room with brown staining and laminate peeling.
#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −0.5
Patient contact items that become contaminated during use shall be cleaned and disinfected after each use. 15A NCAC 18A .1319 (c). Observed no cleaning/disinfectant solution in rehab therapy room to be used on patient contact items after patients rehab session. Housekeeping manager supplied rehab employee’s with approved disinfectant cleaner during time of inspection.
May 18, 2022 96 / 100 · 3 violations
Inspector comments: No points were deducted for the following:
5. Observed build up on vent filters in activity room. Ensure vent filters throughout are cleaned.
**Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).
9. Observed wheel chairs stored in the spa on the 200 hall.
**Toilet rooms shall not be used for storage. See rule .1312 (b).
10. Observed disposable urinals missing label in room 102 and 406.
**Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).
32. Observed damaged cabinet under the sink in the activity room. Observed damaged dresser in room 405.
**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. Observed interior of refrigerators in need of cleaning in nourishment rooms during the inspection. Observed gasket torn in refrigerator in nourishment room.
**Non-food contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. See rule .1320 (c).
40. Observed food in nourishment refrigerator missing label.
**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).
Inspection led by Emily Hartis
#3 · Walls and ceilings cleanable, clean, good repair −2
Observed baseboards missing and wall chipping in the laundry room. Observed ceiling peeling in room 303. Observed wall peeling in nourishment room on 100 hall. Observed wall damage in room 102.
**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 shower chair with staining on the bottom in the spa on 400 hall. Observed staining on shower chair and shower bed torn in the spa on 300 hall.
**Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Observed the lips of medication cups exposed on med carts during the inspection. Stack cups so that the lip of the cup does not pass the top of the storage rack.
**Unused medication cups shall be kept covered or inverted. 15A NCAC 18A .1318 (c).
Oct 8, 2021 95.5 / 100 · 4 violations
Inspector comments: No points deducted for the following items:
2. Floors shall be free of obstacles to cleaning, and shall be kept clean and in good repair. Observed cracked tile in laundry room as well as damaged baseboards throughout facility. Maintenance stated that they have a work order in place to fix repairs.
Water contingency plan incomplete.
The backup water supply plan shall provide for two liters of water per day per person for drinking. The backup water supply plan shall include a plan for either relocating residents or providing an alternative source of water for essential functions such as food preparation, hand washing, bathing, cleaning, dishwashing, laundry and disposal of bodily waste. The amount of water provided for uses other than drinking may be reduced if the plan includes alternatives for water use for services such as laundry and dishwashing. If an assessment determines that tap water is not to be used for drinking, sources shall be prominently labeled or hooded to restrict use and potable water shall be provided.
Inspection was led by Dora Sanders
#3 · Walls and ceilings cleanable, clean, good repair −2
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed 100 wing near room 109 with wall ceiling coming apart. Repair ceiling tile to prevent further damage and hazard to residents. Observed scarred wall near dining table in room 106, water damaged wall behind hopper in soiled utility room, wall scarring behind bed in room 203, and damaged wall by hand sink in laundry room. Discussed with PIC to have maintenance initiate a service request for repairs. Observed dirt and debris in hallway railings throughout facility and paint needing touchup throughout facility. Instruct house keeping staff to increase cleaning frequency and to clean when visibly dirty as well as have maintenance staff touch up paint throughout facility.
#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 pink growth and other debris on shower chairs, mobility chairs, and bath mats as well as stored toiletries n spa in wing 100 and 400 shared spas. REHS recommended to housekeeping staff to keep shared spas as dry as possible by using ventilation system to keep spa areas as dry as possible to prevent buildup of pink growth. REHS also recommended housekeeping staff to not store toiletries in shared spa.
Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed shower head with major leak in shared spa wing 400. Have maintenance staff put in a work order to repair leak.
#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 food debris on linen and mattress in rooms 203 and 209. Ensure that linens and mattresses are kept clean and free of debris and change linen when visibly soiled. Replace ripped pillow In room 305. Points not increased due to allowing house keeping staff to come and clean rooms.
#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 wheel chairs and couch cushions soiled and with debris in wing 400 lobby area. REHS advised PIC to have housekeeping staff clean soiled wheel chairs and to remove debris from under couch cushions. Observed ripped chair seat cushions in 400 wing lobby. REHS advised PIC to repair or replace residents chairs and maintain it in good repair.
May 13, 2021 96 / 100 · 4 violations
Inspector comments: NO POITNS FOR THE FOLLOWING VIOLATION:
#16. Observed no backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f). Back up water supply plan was present during last inspection, head administrator was not present during time of inspection and staff could not find back up water supply plan.
#30. Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c). Observed black build up inside of pill crushers on several medication carts within facility.
#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 bed linen in room 409. Observed minor tears on sheet in room 210.
*NOTE: Inspection was co-lead with Naly Lor and Alexis Welch. Head of Maintenance, Leon, was present during time of inspection.
#3 · Walls and ceilings cleanable, clean, good repair −1
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed baseboard peeling from wall in laundry storage room. Observed touch up paint needed to walls throughout facility. Observed stained ceiling tile near room 303. REPEAT VIOLATION.
#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 staining on shower curtain in room 306. Observed bathing mat in shared spa room with debris build up.
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed staining in toilet in room 114. 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 storage of large containers not utilized for bathing stored in bath rooms throughout facility, Observed wheelchairs stored in shared spa room near 300 hallway. 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 staining on drape in room 407. Observed tears on bed mattress in room 407. Observed debris under couch in living room.
Nov 24, 2020 97 / 100 · 3 violations
Inspector comments: NO POINTS FOR THE FOLLOWING VIOLATIONS:
#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 bed linen in room 407.
#36. 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 roofing of microwave in nourishment room near central nursing station with minor debris build up. Observed shelving of refrigerator with debris build up in nourishment room near central nursing station
*NOTE: Inspection report emailed to Executive Director at the following: Maher.chaikoughli@consulatehc.com
#3 · Walls and ceilings cleanable, clean, good repair −1
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed scuffing and chipping to wall throughout facility particularly in residents rooms behind beds. Observed ceiling stain on hallway of lower 300. Observed ceiling damage near nursing station on 100 hallway.
#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 loose toilet seat in rooms 307 and 406. Improvement has been made from previous inspection thus point value decreased.
#9 · Toilet rooms free of storage, hand wash signs posted −1
Toilet rooms shall not be used for storage. See rule .1312 (b). Observed storage of large containers not utilized for bathing stored in bath rooms throughout facility. Observed wheelchair stored in shared bathroom located in unit 200.
Sep 16, 2019 95.5 / 100 · 3 violations
Inspector comments: NO POINTS TAKEN FOR THE FOLLOWING VIOLATIONS:
#3. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed damage to walls throughout memory care unit in rooms.
#16. Observed an incomplete backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f). Observed back up water supply plan that did not detail all the rules as outlined in 15A NCAC 18A .1313 (f). EHS emailed facility a guidane template for back up 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 box of patient rags stored on the floor in laundry clean linen closet.
#30. Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c). Observed all pill crushers on several medication carts checked during time of inspection with heavy black build up inside of crusher. Clean/Replace.
#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 stains on bed linen in room 209. Observed stain on pillow in room 406.
**Inspection report was signed for by Charles Smith and emailed to charles.w.smith@consulatehc.com
#8 · Facilities conveniently located, clean and in good repair −2
Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b). Observed damage under hand washing sink in activity room due to a leak. Repair. REPEAT VIOLATION.
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). 15A NCAC 18A .1310. Observed grout around toilets throughout facility with black build up. Observed loose toilet seats in rooms 404 and 406. Observed rusted toilet chair in room 209.
#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 bins that container trash and soiled linen in all shared spa rooms checked during time of inspection. REPEAT VIOLATION.
#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 boxes of gloves stored on clean linen cart in clean utility room on 300 hallway. Observed boxes of gloves and diapers on clean linen cart in clean utility room on 200 hallway. REPEAT VIOLATION.
Mar 20, 2019 96 / 100 · 3 violations
Inspector comments: No points were issued for the following:
1. Observed linoleum torn in front of dryer in the laundry room, needs to be repaired.
**Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b).
9. Observed "Broda" chair stored in the shower room on the 300 Hall. Needs to be removed.
**Toilet rooms shall not be used for storage. See rule .1312 (b).
10. Observed urinal not labeled in one resident room. Room is a single but I explained to staff to ensure that they're labeled in all rooms where they are used.
**Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).
32. Observed torn pillows in rooms 302 and 410. Pillows were removed.
**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).
#8 · Facilities conveniently located, clean and in good repair −2
Observed handwashing sink loose, in need of grouting in the laundry room.
Observed underneath cabinets damaged due to water leak in the activity room. Wood needs to be replaced.
**Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
#33 · Linen changed when soiled. Soiled linen handled properly −1
Observed used rags and towels laying out in the shower room. Needs to be removed.
Observed stained blankets stored underneath handwashing sink where a leak had occurred. Blankets were removed.
**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 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
Observed linen carts on the hallway with disposable items stored on them. Ensure that only clean linen are being stored on linen
carts.
**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).
Dec 4, 2018 95 / 100 · 4 violations
Inspector comments: Note: Ensure that Ecolab leaves a copy of when they come check the sanitizer in machines due to clothes being comingled and washed together.
****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).
No points were issued for the following:
3. Observed wall peeling in soiled utility closet near nurse's station near 400 hall. Observed wall peeling behind bed in room 409. Needs to be repainted.
**Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
5. Observed vent filter with build up in Activity room. Needs to be replaced.
**Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).
10. Observed disposable urinals not labeled in rooms 208 and 301. Ensure urinals are being labeled.
**Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).
12. Observed no paper towels at the handwashing sink in bathing suite near the nurse's station. Needs to be provided.
**Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d).
#8 · Facilities conveniently located, clean and in good repair −1
Observed debris underneath shower bed pad in bath suite on 100 hallway. Needs to be thoroughly cleaned.
**Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
Observed toilet in need of recaulking at the base and seat loose in room 111. Strong urine odor in room 111.
**Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
Observed sink loose in need of recaulking in laundry room.
**Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
#13 · Lavatory and bathing hot water between 100 and 116 F −1
Observed water throughout inspection ranging from 98-100F. Increase water temperature so that it falls within allowable range. REPEAT.
**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).
#28 · Adequate storage, area clean, items properly stored −1
Observed items stored directly on the floor in central supply storage and janitor closet (400 and 100 hallway). REPEAT.
**All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −2
Observed linen carts on the hallway with disposable items stored on them. Ensure that only clean linen are being stored on linen carts. REPEAT.
**Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. 15A NCAC 18A .1319 (b).
Jan 18, 2018 97 / 100 · 4 violations
Inspector comments: No Points Deducted for the Following:
8. Observed one loose toilet seat in shower room near 200 Hallway. Needs to be tightened.
**Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
12. Observed no paper towels at the handwashing sink in the Med Room near the 400 Hallway. Paper towels were brought in.
**Provide liquid soap and disposable towels or other hand drying mechanisms at all handwashing sinks. 15A NCAC 18A .1312 (d)
13. Observed water temperature ranging from 98-100F throughout facility during inspection. Encouraged to increase water temperature to ensure compliance of regulations.
**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).
Leon was present during the inspection.
NOTE: Huge improvement from previous inspection. Many structural issues were resolved.
#28 · Adequate storage, area clean, items properly stored −0.5
Observed patient care items stored on the floor in the Clean Utility room near the 400 Hallway and in the Clean Utility room near the 100 Hallway.
**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 debris under couch cushions in living area on the 400 Hallway. Needs to be cleaned at a high enough frequency to reduce accumulation of debris. Observed pillow in room 211 torn. Pillow was discarded.
**All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
Observed items such as gloves, shampoo and disposable underwear stored with clean linen on clean linen cart on the 400 Hallway, 100 Hallway and in Clean Utility room near 200 Hallway. Explained proper storage procedures with staff.
**Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. 15A NCAC 18A .1319 (b).
#40 · Food brought by employees or visitors handled properly −0.5
Observed undated/unlabeled food (tray from kitchen, slice of pizza) in the refrigerator in the Nourishment Room on the 400 Hallway. Food was removed from the refrigerator and discarded.
**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).
Aug 25, 2017 96 / 100 · 4 violations
Inspector comments: No points deducted:
#2. Floors shall be free of obstacles to cleaning and shall be kept clean and in good repair. 15A NCAC 18A .1309(a). Observed damaged flooring in laundry room near can wash and cracked flooring in restroom near 300 hallway.
#3. The walls and ceilings of all rooms and areas shall be kept clean and in good repair. 15A NCAC 18A .1310. Observed larged hole in wall in laundry room near washers and wall in need of touch up paint in restroom near 300 hallway.
#17. Drinking fountains shall be of sanitary angle-jet design, kept clean and properly regulated. 15A NCAC 18A .1314(a). Observed drinking fountain near copy room with calcium build-up. Needs to be cleaned.
#33. Clean bed linen in good repair shall be provided for each individual and shall be changed when in soiled. 15A NCAC 18A .1319(b). Observed torn linen in room 312 and room 105.
#35. Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319(c). Observed torn pillows in room 312, 105 and in physical therapy room.
#5 · Ambient air temperature 65 to 85 F, equipment clean −1
Ventilation equipment shall be kept clean and in good repair. 15A NCAC 18A .1311(b). Observed a/c filters needing to be changed in activity room, living room, rooms 312, 408, 203, 105 and in physical therapy room.
#8 · Facilities conveniently located, clean and in good repair −1
Bathing facilities as required by the licensing agency shall be provided, maintained and kept clean. 15A NCAC 18A .1312(f). Observed stained toilet seat and shower seat in bathing room near 400 hallway and stained toilet in room 203.
#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −0.5
Where disposable bedpans are reused, they shall be labeled with the patients name and date and shall not be used by more than one patient. 15A NCAC 18A .1312 (c). Observed bedpan in room 105 that was not labeled.
#12 · Lavatories have mixing faucet or tempered water, soap hand towel and hand drying device −1.5
All lavatories shall be supplied with hot and cold running water through a mixing faucet, or with tempered warm water, soap, and sanitary towels or hand-drying devices. 15A NCAC 18A .1312 (d). Observed handwashing sink in nourishment room near 400 hallway without soap.
Feb 22, 2017 96 / 100 · 5 violations
Inspector comments: Leon Terrell and Jeff Bardo (ED) were present during the inspection. The 300 hall was completely vacant of residents.
No points were deducted for the following:
4. Observed a light not working in a storage closet. and light cover in need of securing in the main hall storage closet
7. Observed the activity room with a mild cigarette smoke odor. **Smoking rooms shall be ventilated to prevent environmental tobacco smoke from moving into other portions of the building. 15A NCAC 18A .1311 (e).
14. Observed no disinfectant available for the whir pool tub in the 200 hall community bathroom. **A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).
15. Observed the backup water supply plan was unorganized. Create one complete document that included all requires parts of the plan. **A back-up water supply plan guidance document was issed.
43. Observed the thermometer was inaccurate in the central nourishment room. **replace with an accurate thermometer.
#8 · Facilities conveniently located, clean and in good repair −1
Observed elevated toilet chair needed cleaning in the 300 hall shower room. ****Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
Observed a shower chair needed cleaning in the central bathroom. **Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
Observed the sink was very slow to drain in room 114, and the beauty salon sink with pink residue. **Keep all hand washing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
#9 · Toilet rooms free of storage, hand wash signs posted −0.5
Observed the community bathrooms with storage of extra lifts, toilet chairs and other equipment.
**Toilet rooms shall not be used for storage. See rule .1312 (b).
#18 · Drinking utensils properly handled −1
When questioned, several staff member responsible for med carts stated the water pitchers were washed in the nourishment rooms. **Ensure that all drinking water pitchers are properly washed and sanitized daily.
#28 · Adequate storage, area clean, items properly stored −0.5
Observed patient care items were stored on the floor in the central supply closet, the exterior housekeeping storage room, and clean utility and central supply on 200 hall.
**All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
Observed several cabinet door hinges were broken in clean utility room. **Repair doors.
#33 · Linen changed when soiled. Soiled linen handled properly −1
Observed soiled sheets on made beds in rooms 409, 208
**Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).
Observed the towel bin in the beauty shop and in the rehab restroom were not labeled as soiled linen. **Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b).
Jun 24, 2016 93 / 100 · 5 violations
Inspector comments: (NO POINTS DEDUCTED)
4. Observed light out in PT room. Repair light bulb.
13. Observed hot water throughout building registering at 119-122F. Water shall be maintained between 100-116F.
Mr. Sutton was present during inspection.
NOTE: These items are required for back up water supply plan. Next visit have all documents together. Relocation process seen.
(f) The local health department shall be immediately notified if the primary water supply is interrupted for more than four hours. Each institution shall have a plan to obtain a backup water supply in the event that the water supply
is lost for more than four hours. The backup water supply plan shall provide for two liters of water per day per person for drinking. The backup water supply plan shall include a plan for either relocating residents or providing
an alternative source of water for essential functions such as food preparation, hand washing, bathing, cleaning, dishwashing, laundry and disposal of bodily waste. The amount of water provided for uses other than drinking may
be reduced if the plan includes alternatives for water use for services such as laundry and dishwashing. If an assessment determines that tap water is not to be used for drinking, sources shall be prominently labeled or hooded
to restrict use and potable water shall be provided.
#3 · Walls and ceilings cleanable, clean, good repair −1
Observed cracked baseboard in 200 & 300 bath, wall damage in 300 bath, and ceiling peeling outside of PT room.
Observed water stained ceiling in nourishment 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 pitted faucets in residents rooms throughout.
Observed residue on toilet seat in 300 bath.
**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).
#17 · Water fountains clean, good repair, properly regulated −1
Observed calcium build up present at main hall water fountains.
Observed several water fountains not working, pulled from service, and or out of order
**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
Observed drinking utensils not protected from contamination on med cart main hall.
**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 −2
Repeat Non Compliance: Observed stain on linen and or comforters in rooms throughout facility.
**Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).
Nov 23, 2015 92 / 100 · 8 violations
Inspector comments: Randy Smithey was present during the inspection. The 300 wing (ALS) was closed for renovations.3. Observed walls were damaged in some area. Building was undergoing renovation (re-painting/repairs) during the inspection. Continue making wall repairs and finish all walls with paint.Observed the wall base tile was broken damaged in the 300 hall community shower room. **All walls and ceilings shall be cleanable and in good repair.7. Observed cigarette smoke entering the building from the patio. **Smoking must be in a designated area and must not enter the building.4. Observed some lights were not working (Rehab, and storage closet). Keep all lighting in good repair.17. Observed some water fountains were not working. **Keep all water fountains in good repair.***THIS INSPECTION WAS CONDUCTED BY RYAN MICHAUD UNDER THE SUPERVISION OF TASHARRA KENION.
#8 · Facilities conveniently located, clean and in good repair −2
15A NCAC 18A. 1312(a) Toilets shall be kept clean and in good repair. Observed several toilet seats in the shower room in the 300 hall, room # 404, and 406 that were soiled. Observed a loose toilet seat in the shower room, and a rusty elevated in room 404. REPEAT.15A NCAC 18A .1312 (b) Keep all hand washing facilities clean and in good repair. Observed a sink backsplash was damaged in the main hall nourishment room and the sink was dirty (moldy) in the staff lounge.15A NCAC 18A .1312 (a) and (f) Keep all bathing equipment clean and in good repair. Observed shower curtains were stained and/or had residue in several shower rooms.
#9 · Toilet rooms free of storage, hand wash signs posted −1
15A NCAC 18A .1312(b) Toilet rooms shall not be used for storage. Observed storage of activity items in activity room bathroom. REPEAT
#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −0.5
15A NCAC 18A .1312(c) Bedpans shall be labeled with name and date. Observed a bed pan in a patient's room with no name and date.
#14 · Disinfectant accessible, properly used −1
REPEAT - Observed no disinfectant solution in the 200 hall community shower room.**A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).
#16 · Quantitiy and hot water sufficient, backup water supply plan −1
Observed an incomplete backup water supply plan. **Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
15A NCAC .1318(c) Food and utensils used on medication carts shall be handled in a sanitary manner. Observed drinking cups on a medical cart that was not covered or protected in a sanitary manner.
#33 · Linen changed when soiled. Soiled linen handled properly −1
15 NCAC 18A. 1319 Clean linens in good repair shall be provided and changed when soiled. Observed several linens in room # 404 and 211 with soiled linens. Change linens when soiled. Observed some labeled soiled linen containers with worn labels no longer legible, and a pile of soiled/wet towels on the floor in the 200 hall shower room.
#40 · Food brought by employees or visitors handled properly −0.5
15 NCAC 18A .1321(b) Food brought from home by employees shall be labeled with name and date. Observed several food items in several refrigerators with no name and date,
May 19, 2015 92 / 100 · 9 violations
Inspector comments: 14: The 100/200 hall tub without disinfectant. This tub is not in use at this time. **Provide the bottle of disinfectant in this unit at al times.15: Provide documentation that backflow prevention is built into eye wash hoses in shower rooms OR provide in line vacuum breakers on line.16: Provide a new back up water supply plan. Handout provided. 34: Clean linen not covered in the salon. Keep clean linen covered.40: Resident food not dated in the 200 hall nourishment room. Date all food brought into the facility.
#1 · Floors easy to clean, no obstacles, drains where needed −1
Observed: Flooring damaged in the 400 Hall Clean Utility Room. Flooring damaged in the Laundry Room. Excessive amounts of medical records stored in the Record Room and the flooring not clean. Rubber/woven shower floor mats in shower stalls. Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b).Floors shall be free of obstacles to cleaning. 15A NCAC 18A .1309 (a).Floors in intensive care units, bathrooms, showers, hydrotherapy areas, operating rooms, soiled utility rooms and laundry areas shall be of smooth, non-absorbent materials and so constructed as to be easy to clean. 15A NCAC 18A .1309 (a).
#3 · Walls and ceilings cleanable, clean, good repair −1
Repeat: Observed: Peeling wall paper on some halls (repeat). Walls/caulking damaged around some hand sinks (lobby restroom, 201). Wall, tile, and ceiling damage in shower rooms. Several walls in need of paint room previous repairs. The bathroom ceiling water damaged from a sprinkler line in room 407. Walls damaged in the 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
Repeat: Observed: The hand sink blocked in the Laundry Room. The laminate back splash damaged in the 200 hall nourishment room. The toilet base caulk in need of replacement in several areas. Most sink faucets corroded/pitted in rooms inspected. The shower stretcher pad damaged. Several elevated toilet chair frames collecting rust/flaking paint. Shower curtains dirty in shower rooms. The rubber mat flooring with feces on it in a shower room. A loose toilet seat in a shower room.Toilet, hand washing, and bathing facilities must be conveniently located and readily accessible to residents and staff. 15A NCAC 18A .1312 (a).Keep all bathing, toilets, and hand washing equipment clean and in good repair. 15A NCAC 18A .1312 (a),(b), and (f).
#9 · Toilet rooms free of storage, hand wash signs posted −0.5
Repeat: Observed: Excessive amounts of lifts and wheel chairs stored in shower/toilet rooms. Wheel chair parts stored in the bathroom in 405.Toilet rooms shall not be used for storage. See rule .1312 (b).
#17 · Water fountains clean, good repair, properly regulated −1
Observed: The lobby water fountain with calcium buildup. Other water fountains with low pressure.Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a).
#28 · Adequate storage, area clean, items properly stored −0.5
Observed: Items being stored in a can wash in the 200 hall equipment storage room/can wash room. Clean items stored in cabinets of soiled utility rooms (stuffed animals/personal effects).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 −1
Observed: Cabinets dirty in the Activity Room and cabinet doors with laminate damage. The arms of living room furniture in need of stain. Some night stands in resident rooms with laminate damage/wood flaking. A damaged restroom shelf in 405. A damaged chair in 407. A damaged shoe rack in 404. Privacy curtains collecting stains throughout. Damaged cabinet doors in the 400 Clean Utility 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 −1
Repeat: Observed: Multiple soiled linen bins with no label (laundry, rehab, salon, soiled utility room).Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b).
#36 · Approved utensils and equipment, cleaned and sanitized −1
Repeat: Observed: All microwaves dirty in nourishment rooms.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).
Jul 24, 2014 93 / 100 · 7 violations
Inspector comments: Jane Jackson and Mr. Leon Terrell were present during the inspection.#8 - Observed several carts were stored in front of the hand washing sink in the laundry room. **Toilet, handwashing, and bathing facilities must be conveniently located and readily accessible to residents and staff. 15A NCAC 18A .1312 (a).#13 - Observed the hot water throughout the building was 116.4F - 117.5F. **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).#19 - Observed an ice cooler without a drain. **Keep the ice drained. #33 - Observed the "soiled linen" label had worn off the soiled linen cart in the thearapy room. **Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b).
#2 · Floors clean, carpet clean, dry, odor free −1
Observed the carpet was stained and in need of cleaning in the Living Room.**Keep all flooring clean. 15A NCAC 18A .1309 (a).
#3 · Walls and ceilings cleanable, clean, good repair −1
Observed the ceiling damaged with texture cracking and separated from the ceiling (dining room, 100 hall entrance), the wall paper was curling/separating from the wall in the hallway near the laundry room, and the hallway metal window frame was rusty in the activity room. Observed several walls have been repairs with plaster and unfinished. Funish all repaired areas with paint.**Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. **Walls shall be easily cleanable and shall have washable surfaces to the highest level reached by splash or spray in rooms or areas where such occur. 15A NCAC 18A .1310.
#8 · Facilities conveniently located, clean and in good repair −1
Observed a shower chair was soiled, one with bacteria growth in the central bath/shower room, a shower stretcher with debris between the cushion and the support, a shower chair with cracked plastic surface with sharp edges. **Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).Observed some elevated toilet seats with rust. **Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).Observed some sink fausets were corroded, and the sink was clogged in room 113. **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 several stand-up lifts, chairs and other items were being stored in the 200 and 400 hall bathrooms.**Toilet rooms shall not be used for storage. See rule .1312 (b).
#24 · Vermine excluded −1.5
Observed several baby roaches in the laundry room.**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).
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
Observed several rooms with clean linen cart covers left open. **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 · Approved utensils and equipment, cleaned and sanitized −1
Observed the microwaves with food debris on each hall, and the food storage cabinet door was broken in the 400 hall nourishment room.**Non-food contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. See rule .1320 (c).
Dec 30, 2013 91.5 / 100 · 9 violations
Inspector comments: Jane Jackson(administration) and Avery Patterson(housekeeping) were present during the inspection.#4 - Observed lights were not working in the 400 hall shower room and in the main hall nourishment room. **Repair lights.#19 - Observed cups with out handles were being used to scoop ice, and several coolers had undrained ice. Use a handeled scoop to dispense ice, and keep water drained off ice. **Ice shall be handled, transported, stored, and dispensed in such a manner as to be protected against contamination. 15A NCAC 18A .1314 (b).#21 - Observed litter scattered at the dumster area. **Solid waste containers, rooms, or designated areas shall be kept clean. 15A NCAC 18A .1316 (c).#30 - Observed the med cart trash cans stored/affixed on the same side of the med cart as the clean utensils. **Move the trash can/sharps container to the opposite side of the med cart.#42 - Observed a breakfast plate (toast and eggs) was stored in the nourishment room. Breakfast is served at 7am, and time that the food was taken out of temp. control was unknown. Food was discarded. **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). **Potentially hazardous foods served shall be either consumed or discarded within two hours of being removed from temperature control. 15A NCAC 18A .1323 (a)
#2 · Floors clean, carpet clean, dry, odor free −1
Observed the floors were no clean in the shower rooms, and a spilled (dried) substance on the floor in the laundry room closet.**Keep all flooring clean. 15A NCAC 18A .1309 (a).
#3 · Walls and ceilings cleanable, clean, good repair −1
Repeat non-compliance: Observed the ceiling throughout the facility with surface damage; the walls at the sink were damaged in the physical therapy restroom; the ceiling was damaged at the sprinkler head in room 407; the wall was dirty near the sink in the staff restroom (300 hall) wall damage at the shower in the main hall shower room; and some resident rooms with wall damage near beds.**Keep all walls and ceilings clean and in good repair. See rule .1310.
#8 · Facilities conveniently located, clean and in good repair −1
Observed the (food service) hand washing sink in the dinng room was dirty, and some sink faucets were corroded.**Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)Observed the safety straps on a shower chair with black build-up. **Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).Observed an elevated toilet seat with dried urine in room 407; and the toilet in the main hall shower room was soiled.**Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
#12 · Lavatories have mixing faucet or tempered water, soap hand towel and hand drying device −1.5
Repeat non-complaince:Observed no paper towels were supplied to several hand washing sinks: main hall shower room, soiled utility room and the clean supply room (between 200 and 400 halls), 200 hall nourishment room.**Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d).
#14 · Disinfectant accessible, properly used −1
Observed no disinfectant was supplied in the main hall shower room and in the 400 hall shower room.Observed no whirlpool disinfectant available for use in each shower room. Staff stated that the whirlpool tubs were not used. **Provide/re-stock wirlpool disinfectant.**A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .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 (f). **The manufacturer's instructions shall be followed for cleaning equipment with pumps. See rule .1312 (f).
#17 · Water fountains clean, good repair, properly regulated −1
Observed the water fountains were not clean and had clogged drains on the main hall (near guest restrooms) and 200 hall; and the water fountain in the 400 hall living area was not working.**Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a).
#28 · Adequate storage, area clean, items properly stored −0.5
Observed boxes of paper stock (toilet paper and paper towels), and other stock items were stored on the floor in the exterior storage/housekeeping office.**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).
#33 · Linen changed when soiled. Soiled linen handled properly −1
Observed the resident's sheets were soiled in room 407.**Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).
#40 · Food brought by employees or visitors handled properly −0.5
Observed several bags of food brought in by visitors for residents were no labled in the nourishment refrigerators.**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).
Source: Mecklenburg County Public Health – Environmental Health public inspection portal (search for “WILORA LAKE HEALTHCARE CENTER” or State ID 2060400042). Inspection type (routine vs. follow-up) is not published in the county's data.