94.5/ 100

UNIVERSITY PLACE NURSING AND REHABILITATION CENTER

Name: University Place Nursing and Rehabilitation Center
Address: 9200 Glenwater Dr, Charlotte, NC, 28262, US

9200 GLENWATER DR, Charlotte, NC 28262

Rest/Nursing Homes · NC permit/State ID 2060400060

Directions Open in Google Maps What else is nearby

Latest result94.5 / 100

Last inspectedMar 26, 2026

Inspections on record25

On record sinceNov 4, 2013

Score history

Nov 4, 2013Higher is betterMar 26, 2026

Inspections & violations

Mar 26, 2026 94.5 / 100 · 7 violations

Inspector comments: NOTE: - Nurse assistant director: Natalie Faltyn and Maintenance director: Gearod Dupree present during walkthrough inspection.

#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −2

REPEAT 1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair.- Observed debris on flooring underneath shelving in closets, sticky floor, debris on flooring throughout the room or along edges in room 302, 814, 706, 707, 403, and other several residents rooms. Detail cleaning needed. Keep flooring throughout the facility clean.

#7 · Facilities provided, accessible, clean, good repair −2

REPEAT .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 damaged ceiling in front of room 603 need repair. Observed faucet needs repair in room 403. Observed soiled hand sinks/ soiled toilet in activity room, soiled utility room near the front, spa 300 hall, room 315, 506, 600, 701, 706, 914, 911, 113, 106, 101, 302, spa room in arboretum. Observed damaged toilet seat need repair or replace in room 315, 600, 706, 701. Details cleaning needed. Keep all toilets and sinks clean.

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

REPEAT .1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed wheelchair, dining roller table chair lift stored in Spa room rehab, and spa on garden C hall. Only store bathroom related items in bathroom facility. .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 staff restroom in rehab. EHS provided hand washing sings to PIC at the times of inspection.

#17 · Back-up water supply plan available and complete −0.5

REPEAT .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 the incomplete written plan for backup water supply. The facility still has a plan template (filling information) of health department checklist. The facility shall have their own plan according to the need of their facility. The health department checklist is a guide to complete your own written plan. Obtain a complete detailed plan and have available upon request.

#28 · No pest presence; effective pest control measures

General comment: .1317 (a) Pests shall not be present in an institution's building or buildings.- Observed drain flies in room/restroom 106, 600. During inspection, the resident in room 600 and 604 mentioned that aunts are in their room. Ensure to keep the facility free of pests.

#38 · Food service equipment and utensils clean, good repair −0.5

REPEAT .1320 (a) All food service equipment and utensils shall be kept clean and in good repair.- Observed soiled microwaves need cleaning and keep clean in nourishment rooms.

#43 · Food brought into the institution by employees or visitors of patients or residents properly stored, labeled and dated

General Comment: .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 residents food in refrigerator of nourishment room in arboretum without name and date. Ensure to label each items with name and date.

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Nov 3, 2025 97 / 100 · 5 violations

#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −1

REPEAT 1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair.- Observed pantry closet floor 500 hall needs cleaning. Observed dust/debris underneath bed in room 107, 814, need cleaning. Observed soiled plastic cabinet shelving in Spa 300 hall needs cleaning.

#7 · Facilities provided, accessible, clean, good repair −2

REPEAT .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 faucet, need repair in 909. Observed soiled hand sinks in activity room, med room, OT room, dining room, nutrition room, all general common areas throughout the facility, need detail cleaning and keep clean.

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

General Comment: .1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed wheelchair, clothing basket full of hangers, shoes, unused clothes stored in Spa room memory care. Only store bathroom related items in bathroom facility.

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

REPEAT General Comment: .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 the incomplete written plan for backup water supply. The facility is revising the detail written plan at the time of inspection. EHS explain in detail of what needed. Obtain a complete detailed plan and have available upon request. No point at this time.

#38 · Food service equipment and utensils clean, good repair

General Comment: .1320 (a) All food service equipment and utensils shall be kept clean and in good repair.- Observed rusted/peeling on top microwave in nourishment room at the front entrance. Repairing or replacing microwave. Keep all equipment in good repair.

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Jun 16, 2025 97 / 100 · 4 violations

Inspector comments: NOTE: - Director: Shawnna Fairman and a whole administration team present during walkthrough inspection

#1 · Floors and carpets cleanable, clean, good repair; carpet odor free

General Comment: 1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair.- Observed damaged flooring in restroom 107, 909. Repair needed. Observed dust/debris underneath bed in several rooms in memory care unit. Detail cleaning needed and keep clean.

#7 · Facilities provided, accessible, clean, good repair −2

REPEAT .1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed stained toilet seats in resident restrooms 311, hallway restroom front desk. Observed rusted toilet chair in 914, 311. Replace/repair damaged toilet seats/chair commode. Observed spa room floor/wall tiles in 100 hall, need detail cleaning and keep clean.

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

General Comment: .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 without a complete written plan for backup water supply. Obtain a complete detailed plan and have available upon request.

#20 · Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair −1

.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 blue cooler of ice stored on a rolling cart sit out in every hallway. Ice shall be protected and made inaccessible to public if not automatic dispenser. Ice cooler shall be stored safe inside a lock nourishment room.

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Dec 13, 2024 97 / 100 · 2 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 chipped/scuffed doors throughout facility.

#7 · Facilities provided, accessible, clean, good repair −2

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Feb 28, 2024 95.5 / 100 · 9 violations

Inspector comments: NOTE: Maintenance: Mr. Greg Brown. Environmental health Director: Mrs. Chrystal Swinger present at the time of inspection. Admin in training: Mr. Bryce Karstetter. Environmental consultant: Ms. Bu-ita Frindt present during report meeting at the end.

#1 · Floors and carpets cleanable, clean, good repair; carpet odor free

General Comment: 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 closets floor throughout the facility, restroom floor 104, need cleaning/vacuuming and keep clean.

#4 · Lighting at least 10 foot candles, 30 inches above floor

General Coment: .1311 (a) The areas interior to an institution's building or buildings shall be equipped with at least 10 foot candles of light at 30 inches above the floor.- Observed disrepair light bulbs in spa room near the front, Missing light shield cover in some rooms (closet, storage) of the building, need repair or replace.

#7 · Facilities provided, accessible, clean, good repair −2

REPEAT .1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair.- Observed loose toilet seat in restroom at the front hall needs to repair. Observed soiled toilets and hand washing sinks throughout the facility (1008, 1003, 118, 104, 307, 604) except in memory care unit. Need details cleaning and keep clean.

#10 · Handwashing facilities properly located and equipped

General Comment: .1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices.- Observed restroom in admin hall without paper towel and soap. Soiled linen room in 300 hall without paper towels. Ensure to provide all hand washing supplies at all hand sinks at all time. .1312 (d) Handwashing facilities shall be located in an institution in accordance with 10A NCAC 13B .5411, 10A NCAC 13D .3201, 10A NCAC 13F .0305, .1304, and 10A NCAC 13K .1109, .1204, as applicable. Institutions that do not have a handwashing facility located in all areas required by this Paragraph shall not be required to install handwashing facilities if the institution has an approved hand hygiene program. Observed limited access to hand sink in soiled room and spa room some part of the facility. Ensure to not blocking access to hand washing sink at anytime.

#17 · Back-up water supply plan available and complete −1

#28 · No pest presence; effective pest control measures

General Comment: .1317 (a) Pests shall not be present in an institution's building or buildings.- Observed drained flies in in 807 and activity room near by.

#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 damaged on the arms of wheelchair in 118. Damaged tables in Cafe and dinning room near 1000 hall. Need repair or replace.

#33 · Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled −1

.1319 (b) A resident's bed linens shall be changed when no longer clean.- Observed soiled bed linens, blanket, pillow cases in room 506, 604, 1003, 807, 104. Need replace and provide clean bed linens.

#34 · Linens provided by the institution properly cleaned and sanitized

General Comment: .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 without the laundry records showing the concentration of chlorine solution as it use to sanitize the facility linens. Obtain and maintain the records.

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Sep 8, 2023 92 / 100 · 8 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 flooring in oxygen room on admin hall and 1000 hall closet floor need deep cleaning, and keep clean. Observed pick mildew of flooring in 300 -500 hall bath, need cleaning and remain clean -0 pts-

#7 · Facilities provided, accessible, clean, good repair −2

REPEAT .1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed toilet need cleaning/better cleaning in room 600, 700, 900 hall restroom, 300-500 hall bath, 113, 802. Observed loose seat in room 811, 905, 900 hall restroom, 113, need repair or replace. Observed damaged toilet seat that need replace in room 307, 707. Observed rusted or damaged toilet seat/chair in need of repairing or replacing in room 600, 310. Observed slow drain in hand sink in room 501, 600, need repair. Observed leaks toilet in room 805, need repair or replace. -2 pts-

#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 two outdoor umbrellas and files boxes store in toilet room on admin hallway. Remove all items that are not bathroom related. -0.5 pts-

#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. Observed cleaning employee does not have knowledge about the amount of contact time for cleaning and disinfecting surfaces. Cleaning manager will educate all cleaning staff for effectively cleaning. -0 pts-

#16 · Hot water between 105°F and 116°F −3

REPEAT .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 excess the range between 117F to 126F (900 hall nourishment room behind nursing station, 902, 501, salon, 905, 204, 103, 108, 307, 310, 300 hall dining, 802. Adjust hot water to be between 105F - 116F and remain in the range. VERIFICATION NEEDED. -3 pts-

#17 · Back-up water supply plan available and complete −1

REPEAT .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 written plan for backup water supply. EHS emailed backup water supply plan checklist to administer at the time of inspection. The facility will get the plan put together -1 pts-

#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 cooler on the roller cart sit in the hallway upon entrance of the building. Observed the unlock room where ice cooler stored in it in 800 hall. EHS asked for the receptionist to move the cooler into a lock storage room and locked the room where ice can be protected. -1 pts-

#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 very soiled microwave in 1000 hall dining and pink mildew inside the ice machine in nourishment room near the front entrance, need details cleaning and keep clean. -0.5 pts-

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May 4, 2023 92.5 / 100 · 10 violations

Inspector comments: *NOTE: Housekeeping Manager, Kevin Willoughby, was present during time of inspection. EHS advised facility the the employee health policy has been extended to all employees within facility and not just limited to kitchen staff. EHS emailed administrator a back up water supply plan procedure and vomitus/diarrheal incidence procedure. upl63-admin@universityplacenursing.com

#7 · Facilities provided, accessible, clean, good repair −2

.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed detailed cleaning needed to hopper in soiled utility room located on rehab unit. Observed hot water faucet not working at handsink in shared spa room located in memory care unit. Observed detailed cleaning needed to shower tiles and toilet in shared spa room located in memory care unit. Observed black build up at bottom of shower curtains in shared spa room located on 100 hallway. Observed detailed cleaning needed to toilet and shower tiles in shared spa room located on 100 hallway. Observed loose toilet seat in room 1002. Observed brown build up on toilet rim in room 912. REPEAT VIOLATION.

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

.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 handwashing signs missing at employee toilet rooms sporadically throughout building.

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

.1312 (c) When disposable bedpans, emesis basins, and urinals are reused, they shall be labeled so that they are associated with an individual resident. Observed several urinals not labeled according to notated rule (room 903 & room 908).

#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 paper towels at handsink in shared spa room located in memory care unit and 100 hallway.

#16 · Hot water between 105°F and 116°F −1.5

.1313 (d) Institutions shall provide water heating facilities. Hot and cold running water under pressure shall be provided to carry out all operations. Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities. Observed hot water not within the required range in the following areas: 95F room 903, 95F room 908, 94F room 912, 92F room 1002.

#17 · Back-up water supply plan available and complete −1

.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 no written plan for backup water supply. REPEAT VIOLATION.

#38 · Food service equipment and utensils clean, good repair

.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed detailed cleaning needed to microwave in memory care activity room.

#42 · Food and food supplies from approved sources; properly stored and handled −1.5

.1321 (a) All food and food supplies provided by an institution for consumption by residents shall be from approved sources, stored, and handled as set forth in 15A NCAC 18A .2600. Per conversation with several nursing staff, they are obtaining drinking water for residents to consume meds for nourishment rooms that are equipped with a handwashing sink only. EHS advises facility to obtain drinking water from an approved source only (bottled drinking water, food prep sink in kitchen, water fountains). REPEAT VIOLATION.

#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 no thermometer in refrigerator located in memory care unit activity room.

#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. Per conversation with administrator, facility has the vomit/diarrhea clean up kits. EHS provided facility with a template procedure to clean up diarrheal/vomitus incidents.

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Nov 9, 2022 88.5 / 100 · 7 violations

Inspector comments: NO POINTS FOR THE FOLLOWING VIOLATIONS: #2. Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed floor in room 603 in need of cleaning. Observed detailed cleaning needed to flooring in unoccupied rooms that are being used for storage on 1000 hallway. #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 disposable cups being stored on floor in dietary closet and boxes of toilet paper being stored on floor in storage room 1012. #30. Unused medication cups shall be kept covered or inverted. 15A NCAC 18A .1318 (c). Observed medication cups stored on med cart in memory unit not covered or inverted. #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 microwaves and refrigerators throughout in facility in nourishment rooms. *NOTE: EHS James Limer lead inspection with EHS Alexis Welch. Greg Brown, Maintenance supervisor, was present during time of inspection. Report emailed to admin at: upl63-admin@universityplacenursing.com upl63-don@universityplacenursing.com upl63-maint@universityplacenursing.com

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

Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed toilets with build up of soil in several patient bathrooms. EHS encourages facility to complete detailed cleaning to toilets throughout to include toilet basin and outside of toilets. Observed loose toilet seat in room 113. Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed black build up on shower tiles in shard spa room on memory care unit and 100 hallway shared spa room. Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b). Observed loose handsink faucet in memory care shared spa room. REPEAT VIOLATION.

#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 room on 100 hallway to include a stereo and chairs/furniture. REPEAT VIOLATION.

#14 · Disinfectant accessible, properly used −2

A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). Observed community spa located in memory unit and 100 hallway missing EPA registered disinfectant. REPEAT VIOLATION.

#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). EHS emailed facility a guidance document outlining the items needed for a back up water supply plan. REPEAT VIOLATION.

#19 · Ice protected, dispensed, equipment clean in good repair −2

Ice shall be handled, transported, stored, and dispensed in such a manner as to be protected against contamination. 15A NCAC 18A .1314 (b). Observed ice chest stored in hallway unattended and not locked on several hallways. 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 pink build up inside ice machine located on 300 hallway nourishment room. 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 hygienic items stored on clean linen carts throughout facility. REPEAT VIOLATION. All common linen including sheets, pillow cases, absorbent pads, towels, and wash cloths provided by the facility must be sanitized between users with an EPA registered laundry sanitizer or by other methods described in 15A NCAC 18A .1319 (b). Observed no documentation detailing how much bleach is pumped into system when commingling of linens is occurring.

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

All food and food supplies provided by an institution shall be from sources that comply with 15A NCAC 18A. 2600. Per nurse on memory care unit water is filled from handsink in medication room to give to residents to take their medication. EHS advises facility to obtain drinking water from an approved source (food prep sink in kitchen, water fountains, bottled drinking water).

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Jun 27, 2022 87.5 / 100 · 8 violations

Inspector comments: NO POINTS FOR THE FOLLOWING VIOLATIONS: #3. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed ceiling damage outside of room 403. #4. All areas shall have sufficient illumination. Maintain 10 foot candles of light at 30 inches above the floor in all areas other than food service areas. 15A NCAC 18A .1311 (a). Observed several lights not operating in spa room located within rehab unit. #11. Except for the stipulations stated in rule .1312 (d), handwashing sinks shall only be used for handwashing. 15A NCAC 18A .1312 (d). Per conversation with employee in memory care unit, she fills water up from handsink located in activity room, for pitcher of water. #15. Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d). Observed no back flow preventer device stored on shower wand in memory care spa room. #21. Solid waste containers, rooms, or designated areas shall be kept clean. 15A NCAC 18A .1316 (c). Observed liquid under compactor dumpster. EHS advises facility to clean liquid under compactor to help against rodents. EHS advises facility to ensure compactor does not have a hole. #40. Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply and shall be labeled with the name of the person to receive the food and the date the food was brought into the facility. 15A NCAC 18A .1321 (b). Observed container of food with name and no date in refrigerator located in nourishment room on 300 hallway. Per maintenance it was an employee’s food. *NOTE: ENVH Supervisor, Shawn Blackmon, was present during time of inspection. Greg Brown( Head of Maintenance), Jay Shifrin (Environmental Consultant), Eric Hudson (ENVH Manager). Report was went over witH Administrator, Coleen Anderson. Report emailed to: upl63-don@universityplacenursing.com

#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 detailed cleaning needed to spa rooms throughout facility (Observed black build up inside shower grout within spa rooms throughout facility). Observed white bathing mat with slits in shared spa room on 100 hallway. Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed several loose toilet seats throughout facility. Observed detailed cleaning needed to toilets throughout facility. (Toilet soiled room 403, toilet soiled room 1004, loose toilet room 704, brown staining on toilet seat in room 704). 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 in all shared spa rooms throughout facility to include, soiled linen, boxes of supplies, clothing, furniture, etc. Observed boxes stored inside of tub in rehab area. Per conversation with facility rehab area is currently not in use. EHS observed soiled linen and clothing stored on the floor in middle of rehab spa room. REPEAT VIOLATION

#14 · Disinfectant accessible, properly used −1

A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). Observed no EPA registered disinfectant accessible to all shared spa rooms throughout facility. Per housekeeping management, CNA clean shower rooms after each use, EHS was unable to get a clear answer on where the EPA disinfectant is held for access to CNA’s to clean. REPEAT VIOLATION.

#16 · Quantitiy and hot water sufficient, backup water supply plan −2

Observed an incomplete backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f). REPEAT VIOLATION.

#19 · Ice protected, dispensed, equipment clean in good repair −2

Ice shall be handled, transported, stored, and dispensed in such a manner as to be protected against contamination. 15A NCAC 18A .1314 (b). Observed ice chest stored in hallway unattended and not locked on 300 hallway. 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 pink build up inside ice machine located on 300 hallway nourishment room. REPEAT VIOLATION.

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

All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). Observed patient contact items stored on the floor in rehab area storage closet. Observed brown blankets in large clear plastic bags stored on the floor in clean linen closet within memory care.

#33 · Linen changed when soiled. Soiled linen handled properly −2

Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b). Observed all green soiled linen carts throughout facility not labeled “soiled linen” Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed staining on linen in rooms 113, 114, and 1004. REPEAT VIOLATION.

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

All common linen including sheets, pillow cases, absorbent pads, towels, and wash cloths provided by the facility must be sanitized between users with an EPA registered laundry sanitizer or by other methods described in 15A NCAC 18A .1319 (b). Observed common linen’s being commingled with no documentation from facilities services, Ecolab, detailing the amount of sanitizer being pumped into system per cycle. 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 clean linen carts throughout facility being stored commingled with an employees purse, hygienic items, gloves, diapers, etc. REPEAT VIOLATION.

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Oct 7, 2021 88 / 100 · 9 violations

Inspector comments: NO POINTS TAKEN FOR THE FOLLOWING VIOLATIONS: #2. Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed staining on carpet located on administration hallway. #32. All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a). Observed staining on drapes in room 116. Observed handle to microwave in memory care nourishment area broken. #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 blanket with holes in room 705. *NOTE: Maintenance Greg was present during time of inspection along with EHS Mia Lowery. EHS went over report with Director of Nursing Angela Ridenhour, report emailed to her at upl63-don@universityplacenursing.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 touch up needed to door frames throughout building. Observed stained ceiling tile in laundry room over large industrial washer. Per conversation with Head of Maintenance the stains are from an old leak. EHS advises facility to ensure no active leak is occurring and to repair/repaint over stained ceiling. REPEAT VIOLATION

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

Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed large tubs in all shared spa rooms checked during time of inspection with storage stored inside of them and in need of general detailed cleaning. Observed linen stored on the floor in disarray in shared spa room located on 900 hallway. Observed black build up inside of floor tiles located in shower in shared spa room located near small rehab gym. Observed build up under toilet lid in room 801. Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed heavy feces build up under toilet lid in room 116. Observed loose toilet seat in room 600. Observed staining under toilet lid in shared spa located on 300 hallway. EHS advises facility to increase cleaning frequency of bathing and toileting items throughout facility.

#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 to include gloves, diapers, large bins, and linen stored in shared spa room located across from large rehab gym. REPEAT VIOLATION

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

Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). Observed no paper towels at hand sink located at restroom near main entrance.

#14 · Disinfectant accessible, properly used −2

#16 · Quantitiy and hot water sufficient, backup water supply plan −1

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

Ice shall be handled, transported, stored, and dispensed in such a manner as to be protected against contamination. 15A NCAC 18A .1314 (b).Observed ice chest stored in hallways throughout facility unlocked and unattended.

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

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 personal hygiene items, diapers, and gloves stored with clean linen on clean linen carts throughout facility. 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 common linens being commingled in facility with no documentation detailing proper sanitization. EHS advised housekeeping management to have their service representative to leave facility with documentation after their visits detailing sanitizer concentration going into the system during each use.

#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 several patients coming and going out of smal rehab gym and no disinfectant being used to wipe down equipment in small rehab gym. Per conversation with staff member facility had recently ran out of purple top disinfectant wipes.

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Jun 28, 2021 96.5 / 100 · 3 violations

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

REPEAT Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed walls inside bathroom of room #814 in need of general cleaning; Observed wall damage inside spa on #100 hall in need of repair. Observed ceiling damage (water) inside (Soiled Linen) room in REHAB unit in need of repair.

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

Toilet rooms shall not be used for storage. See rule .1312 (b). Observed (wheel chairs, room chairs) stored inside (SPA / Shower rooms) throughout facility.

#14 · Disinfectant accessible, properly used −1

A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). Observed all (SPA / Shower rooms) not having approved disinfectant accessible during inspection.

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Dec 1, 2020 97 / 100 · 3 violations

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

Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed ceilings in most (storage closets / maintenance closets / laundry room) having old water damage in need of repair.

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

Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). Observed can light inside shower of resident room #313 falling out of ceiling in need of repair.

#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 very loose toilet seat inside resident room #1003 in need of repair.

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Jan 23, 2020 95.5 / 100 · 4 violations

Inspector comments: Keep Walls and ceilings in good repair. 15A NCAC 18A.1310. Observed cracks on walls in staffs rest room at the Rehab area and needs to be repaired. Observed leaks in one of the bathrooms in the 300 wing area. PIC indicated that it will be fixed. 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 hairs and food debris build up on the furniture in the front lobby seating area of the nursing home. The furniture needs to be cleaned. Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed build upon on the toilet seats in room 110 and also in the spa room in the 100 wing nursing home area. Through discussions with nursing and housekeeping staff, it appears that the disinfectant contact time is not being left on surfaces for the minimum 10 minutes as directed by manufacturer. Make sure all necessary staff are aware of disinfectant contact times.

#14 · Disinfectant accessible, properly used −2

A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). Observed no detergents in the Spa opposite room 106.

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

Ice shall be handled, transported, stored, and dispensed in such a manner as to be protected against contamination. 15A NCAC 18A .1314 (b). Observed the ice scoop laying directly on top of the ice with the handle touching the ice. PIC removed the the scoop.

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

Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a). Observed a box of can juice and and single use items stored under the hand washing sink in the med room at the rehab area. Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a). Observed patient bathing items, stored in the spa room and the clean linen storage area. All needs to be stored in a designated area.

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

Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed stained linens in rooms 106, 110, 805, 1010. needs to be changed.

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Nov 20, 2019 93.5 / 100 · 7 violations

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

Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310 Observed ceiling inside laundry room damaged in need of repair.

#8 · Facilities conveniently located, clean and in good repair −1

REPAIR Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed toilet seat very loose in resident room #1012 in need of repair.

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

Toilet rooms shall not be used for storage. See rule .1312 (b). Observed non-shower related items (chairs) stored inside spas.

#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −1

Label all disposable bed pans / urine collection containers with the residents/patients name and date. 15A NCAC 18A .1312 (c). Observed numerous resident bathrooms (shared by 4 residents) having bed pans and urine collection containers without labeling stored together. (#1003, #1005, #1002)

#14 · Disinfectant accessible, properly used −1

A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). Observed disinfectant not available in spas throughout facility.

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

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 storage rooms throughout having too much storage with large amounts on floor in need of removal to facilitate cleaning.

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

REPEAT All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a). Observed bed frame damaged in resident room #414 in need of repair / replacing.

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Jun 3, 2019 87 / 100 · 11 violations

Inspector comments: NO POINTS: #9: Toilet rooms shall not be used for storage. See rule .1312 (b). Observed wheelchairs, jerry chairs stored in bathrooms. #12: Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). Observed several paper towels dispensers empty in locked rooms like med rooms, soiled utility rooms, etc CDI-filled #14: 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). Observed staff did not know to clean with a detergent before disinfection step. Disinfectants used had 10 minute contact times. Staff members did not know contact times. (through discussion with several staff). #15: Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d). Observed no backflow preventers in beauty salon or 1 or 2 shower wands in spa rooms. #16: Observed an incomplete backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f). Observed incomplete back-up water supply plan. New ED had one started, not completed. #21: The rooms, enclosures, designated areas, and containers shall be adequate for the storage of all solid wastes accumulating on the premises. 15A NCAC 18A .1316 (c). Observed meat bones, grease and trash on ground outside compactor door. Keep this area clean so pests/flies are not attracted. #30: Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c). Observed soiled med carts (facility has new med carts but haven't been switched to yet). Observed soiled pill crushers, keep clean. Call for reinspection when ready 980-314-1620 ask office assistant to enter a service request

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

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). Observed tiles in roll in showers in spa rooms with black build up in grout. Needs better cleaning All floors subject to flood-type cleaning shall be of nonabsorbent materials, shall be sloped to drain and provided with floor drains. 15A NCAC 18A .1309 (b). `Observed grout not sealed in remodeled spa rooms. Seal grout before opening for use.

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

Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed walls and ceilings in disrepair throughout, except newly remodeled areas (facility under remodel)

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

Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). Observed dusty fan in laundry room. Keep fan clean. Ambient air temperatures shall be maintained in the range of 65°F to 85°F. 15A NCAC 18A .1311 (c). Observed air conditioner broken in small portion of building. Keep occupants out of stuffy areas.

#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 shower beds and shower chairs with hair/build-up. Clean and disinfect between patients, including the under sides. Shower door track loose in room 505. Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed fecal matter on the undersides of several toilet seats. Clean more thoroughly including undersides. Observed several broken or missing toilet paper roll holders throughout building. Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b) Observed hand sinks not being cleaned on old PT side of building. Some of the old sink fixtures are corroded. Handwashing facilities shall be provided in kitchens, food preparation areas, sterile supply processing areas, medication rooms, laundry areas, and soiled utility rooms. 15A NCAC 18A .1312 (d). Observed refrigerator used for patient foods in storage room without hand sink. Observed refrigerator and ice machine in room without hand sink, unlabeled room off lobby. Any area where food is stored must have a hand sink. Keep hopper clean.

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

All ice machines and storage chests which are accessible to the residents and the public shall be automatic ice dispensing machines. 15A NCAC 18A .1313 (b). Observed unprotected ice chest in hallway. Ice where residents or visitors can access have to be automatic dispensing. 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 heavy build-up in ice machine and ice scoops and ice scoop holders with scale build-up. Scoops and scoop holders need to go to kitchen for cleaning daily.

#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 phlebotomy supplies, bathing supplies, crash cart supplies disorganized. In memory care spa room wash basin containing new and used toothbrushes, hair brushes, razors, etc. stored intermingled. Same spa room also had an obstructed hand sink and whole bags of clean linens.

#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 debris under cushions of common furniture. Mattress in room 908 stained, cover unzipped. Observed bedside and over bed tables in disrepair throughout (being replaced during remodel)

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

Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed soiled sheets and pillow cases rooms 812 and 908.

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

Cooking surfaces of equipment shall be cleaned at least once each day. 15A NCAC 18A .1320 (c). Observed couple of rusted microwaves that need replacing. Clean spills from refrigerators. Observed one water pitcher on med cart with pink residue, wash in kitchen every 4 hours.

#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

Medications shall be stored in a manner which will not contaminate food or food products such as in separate covered containers or in separate refrigerators. 15A NCAC 18A .1323 (a). Observed medications stored above food in fridge in Memory care med room.

#47 · Hands properly washed or decontaminated −1.5

Handwashing shall include a vigorous rubbing together of all surfaces of lathered hands for at least 10 seconds followed by thorough rinsing under a stream of water and drying with individual disposable towels or hand drying devices. 15A NCAC 18A .1324 (b). Observed employee helping resident to bathroom/shower without hand washing afterwards (gloves still on)

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Oct 10, 2018 93 / 100 · 5 violations

Inspector comments: FACILITY HAS 800 AND 700 HALL AND SOME OF 900 HALL EMPTY AND UNDER CONSTRUCTION DURING INSPECTION. FACILITY RUNNING UNDER NEW MANAGEMENT SINCE LAST INSPECTION (SAME OWNER).

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

REPEAT Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed peeling wall paper throughout facility and inside resident rooms; Observed stained/water damaged ceiling tiles in need of replacing in hallways of facility; Observed scuffed walls in need of touch-up paint throughout facility.

#4 · Lighting at least 10 foot candles 30 inches above floor −1

All areas shall have sufficient illumination. Maintain 10 foot candles of light at 30 inches above the floor in all areas other than food service areas. 15A NCAC 18A .1311 (a). Observed janitorial closets having non-functioning lights.

#13 · Lavatory and bathing hot water between 100 and 116 F −1

Maintain the hot water at all resident accessible hand washing sinks and bathing facilities within the temperature range of 100°F to 116°F. 15A NCAC 18A .1312 (e). Observed hot water measuring above 116F in all resident rooms (128F) excluding (SPARKS) wing which was observed at 108F.

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

REPEAT All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, Venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a). Observed chipped Laminate on all dressers and night stands in all resident rooms; Observed chipped laminate on drawers and cabinetry at nurse stations.

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

REPEAT Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed resident pillow cases soiled in SPARKS wing of facility; Observed crumbs collected on sheets in numerous rooms in facility; Observed resident in room #903 missing pillow case. (POINTS NOT INCREASED DUE TO IMPROVEMENT).

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May 1, 2018 84 / 100 · 10 violations

Inspector comments: NO POINTS WERE TAKEN FOR THE FOLLOWING: #4 - Observed light out in janitor closet 100 hallway. Observed damaged light in rehab spa. Observed damaged window in the OT room. **All areas shall have sufficient illumination. Maintain 10 foot candles of light at 30 inches above the floor in all areas other than food service areas. 15A NCAC 18A .1311 (a). #14 - Observed head house keeper state that chemical used for toilets and bathing equipment is left for a contact time of 1 minute. Manufacturers instructions states 10 minute contact time is required for this chemical to be used as a disinfectant. Observed disinfectant to be inaccessible in spas. House keeping stated disinfectant was stored in locked cabinet within but no one knew the combination. Observed therapist in rehab room state that the contact time for disinfectant wipes was one minute. Manufactures label states 2 minutes is required. **A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). #26 - Observed trash cans being stored behind dumpster with garbage and standing water in them without lids. Observed dead insects on floor in need of cleaning in electrical closet on 100 hall. **There shall be no fly or mosquito breeding places, rodent harborages, or undrained areas on the premises. 15A NCAC 18A .1317 (c).

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

REPEAT Observed floor damage throughout hallways and in 106. **Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b).

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

REPEAT Observed touch-up paint needed throughout facility including patient rooms, med rooms, spark hallways, dining rooms, and janitor closets. Observed peeling wallpaper in 116, spark unit, 408, 403, 300 hall, 503, 1008, and 800 hall. Observed wall damage throughout facility including patient rooms and restrooms, spark unit, activity rooms, rehab room, OT room, and dining rooms. Observed base boards detaching from walls in 100 hallway, spark unit, and rose dining. Observed soiled walls in spark unit. Observed ceiling damage in spark unit, 300 hall, and laundry room. Observed doors damaged throughout including patient rooms, spark unit, bathrooms, and dining rooms. Observed hand rails peeling in spark unit. **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 soiled toilet seat in 116, Observed hoppers to be soiled in need of cleaning throughout soiled utility rooms. 309, and 1008. Observed caulking needed around sink in 116, and caulking needed around base of toilet in 106, 403, and 700. Observed build-up in the shower grout and broken tiles in shower of spark unit spa. Observed damaged shower curtains in the rehab spa. **Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). **Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).

#18 · Drinking utensils properly handled −2

REPEAT Observed water pitcher labeled 116A and 116B on same water pitcher in 116. Observed water pitcher in 805 without label. **Label all disposable water pitchers with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a).

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

REPEAT Observed diapers being stored on the floor in the med prep room on 100 hall, and storage on floor in rehab storage closet. Observed patient personal items being stored on the floor in the spark unit storage room. Observed temporary storage rooms on 1000 hall with excessive storage, packed to tightly for regular cleaning. Observed items being stored within the splash zone of hand sink in med prep 100 hall and spark unit. Observed chemical spray bottle being stored with paper towels on janitor cart in 100 hall. **Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a). **All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).

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

REPEAT Observed pill crushers in need of cleaning on med carts throughout. **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

REPEAT Observed damaged furniture in patient rooms throughout where drawers are difficult to open and off the tracks, in the restorative activity room, library, and lobby. Observed peeling laminate on cabinets and patient closet doors throughout and damaged cabinets in 116 and 106. Observed bed remote with debris and build-up in the cracks and crevices in 106. Observed heavily soiled drawers with food debris in 309. Observed cabinets in need of cleaning in rose dining room and 309. Observed torn rehab equipment in rehab room and peeling bed positioning wedge in 805. Observed stained and soiled pillows in rooms 116 and 408. **All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).

#33 · Linen changed when soiled. Soiled linen handled properly −2

REPEAT Observed stained sheets throughout rooms. Observed beds to be made up with debris left in sheets in rooms 116, 106, 908, and 805. Observed stained divider curtains in 116, 403, 700, and 805. Observed damaged and worn linen in rehab room. **Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).

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

REPEAT Observed wipes being stored directly in contact with clean linen on clean linen cart of 900 hall. Observed clean linen commingled with toileting supplies in 700 hall clean linen closet. Observed clean linen shelving in need of repair in several closets. **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).

#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 pudding cups on med carts that state "Keep Refrigerated." Nurses stated that pudding is opened and kept for 24 hours on carts to use at med pass. Puddings were not being kept under temperature control and were at room temperature today. Puddings must remain under temperature control or must be labeled and discarded after two hours when removed from temperature control. Puddings voluntarily discarded today. **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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Dec 28, 2017 87 / 100 · 10 violations

Inspector comments: NO POINTS WERE TAKEN FOR THE FOLLOWING: #1 - REPEAT Observed rusted floor tile in med room on 100 hallway. #2 - Observed floors in need of cleaning in various closets throughout. #10 - Observed bedpan unlabeled and in need of cleaning in 103. #17 - Observed no current pet vaccination records onsite. Observed TDI cards for therapy dogs but no records associated with these animals. Provide and maintain current records onsite. By end of inspection records were provided. #30 - Observed detail cleaning needed in med cart drawers. Observed pill crushers in need of cleaning on med carts throughout. #35 - Observed build-up on therapy equipment and torn weights in therapy room. Observed hair comb sanitizer with debris in beauty salon in need of changing.

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

Observed peeling wall paper and wall damage throughout building in hallways, activity rooms, resident rooms, nourishment and med rooms, and dining rooms. Observed hole in the wall of room 402, behind the bed in 109, and holes in the wall of 309. Observed foam tape in need of removal from wall in 100 hall. Observed door damage in 100 spa. Observed wall damage in the bathroom of 302. Observed missing window sill in room 809. Observed loose baseboards and loose FRP board in several areas throughout. **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 tile missing in 100 hall spa and damaged tiles in various areas of other spa bathrooms. Observed missing grout in shower of 505 and cracked tiles in shower of 705. Observed shower head in need of cleaning in 505 and 705. Observed cleaning needed on the bottom of shower chair in 900 hall spa. Observed debris on underside of shower table and mat in 100 and 700 spa. Observed caulking needed around sink in 901. Observed cracked sink bowl in room 402. Observed tub and shower chairs in need of cleaning and pink and black build-up in grout in spark unit. Observed toilet chair bowl with urine in 700 hall spa. Observed chipped tub in 100 spa. **Keep all bathing equipment, toilet equipment, and hand washing facilities clean and in good repair. 15A NCAC 18A .1312 (a), (b), and (f).

#9 · Toilet rooms free of storage, hand wash signs posted −1

REPEAT Observed chairs being stored in restroom 109, 103, and 302. **Toilet rooms shall not be used for storage. See rule .1312 (b).

#14 · Disinfectant accessible, properly used −1

Through discussion, observed facility wiping spa tubs with a disinfectant. Manufacturers procedures must be followed. **The manufacturer's instructions shall be followed for cleaning equipment with pumps. See rule .1312 (f).

#18 · Drinking utensils properly handled −1

REPEAT Observed unlabeled water pitcher in room 809. **Label all disposable water pitchers with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a).

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

REPEAT Observed toileting items being stored on the floor in the med-prep supply room. Observed storage under the sink in the 100 hall med room. Observed manipulatives being stored on the floor in the spark storage closet and gowns and face masks on the floor of the 200 hall storage closet. Observed chemicals being stored with gloves in 700 spa. Observed water cups being stored on the floor in central supply. Observed disinfectant wipes being stored over patient contact items in rehab storage closet. **Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a). **All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). **Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a).

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

REPEAT Observed damaged laminate on armours in rooms 109, 402, and 302. Observed damaged table legs in spark unit dining area, damaged bedside table in 801, and bedside drawer stuck in 505. Observed cleaning needed in dressers throughout. Observed drawers and cabinets in need of cleaning throughout soiled utility, nourishment, and med rooms. Observed damaged cabinet and end table in 901. Observed stained curtain in rooms 409 and 402. Observed shower curtains in spa bathrooms with build-up on the bottom edges. Observed chair damage and bed table damage in 103. Observed torn and stained mattress in 402 and ripped mattress in 705. Observed cleaning needed on bed remotes.**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 debris in mattress in 103 and 201. Observed soiled linen unlabeled in rehab room. Observed soiled sheet and bed pad that had been made as clean in 309. Observed debris in bed and stained sheet in 705. **Soiled laundry shall be handled and stored separately from clean laundry using separate cleanable carts or bags. 15A NCAC 18A .1319 (b). Provide record of sanitization of comingled laundry. Observed no proof of sanitization on site today.

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

Observed clean linen being stored under the sink in room 505. Observed clean linen stored with other supplies in 700 hall clean supply, in rehab room cabinet, and in spark spa cabinet. Observed clean linen covers used to cover linen carts in hallways made of mesh where contamination is still possible, observed a stained linen on one of these carts with coffee stained on the mesh cover and the linen below. Observed vinyl linen covers with large holes being used to cover linen in spark unit. **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 cleaning needed in refrigerators throughout building. Observed nurse state that med cart water pitchers are cleaned in the nourishment rooms with hand soap. EHS explained that water pitchers need to be taken to the kitchen daily to be properly sanitized. **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).

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Jun 30, 2017 90 / 100 · 6 violations

Inspector comments: NO POINTS WERE TAKEN FOR THE FOLLOWING: #1 - Observed rusty floor tile in med room on 100 hallway. Observed cracked floor tile in several resident rooms and hallways throughout building. #13 - Observed hot water only reach 93F in 300 hallway spa bathroom. **Maintain the hot water at all resident accessible hand washing sinks and bathing facilities within the temperature range of 100°F to 116°F. 15A NCAC 18A .1312 (e). #6 - Observed growth on the wall behind the toilet in room 200. **Moisture shall be controlled such that there is no evidence of microbial growth on interior surfaces and objects. 15A NCAC 18A .1311 (d). #28 - Observed cleaning needed in cabinets and drawers in the rose dining room. Observed cabinets in need of repair where the are peeling and paint is chipping on cabinet handles in several areas including med and nourishment rooms.**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). **Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b).

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

REPEAT Observed wallpaper peeling up and damaged on most walls throughout facility. Observed cleaning needed of FRP wall in the 500 hallway soiled utility room. Observed wall damage in the rose dining room. Observed baseboards peeling away in several areas throughout building. Observed wall damage in the nourishment room on the 100 hallway. Observed chipping paint on doorways throughout building. Observed cleaning needed behind hallway railings. Observed absorbent particle board on the wall behind toilet in need of sealing in the 411 bathroom. **Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.

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

Observed base of hand sink faucet and cabinet underneath hand sink in need of cleaning in the 100 hallway med room. Observed cleaning and repairs needed to the hopper in the soiled utility room on the 300 hallway and cleaning needed on the hopper in the 500 hallway soiled utility room. Observed shower tile in need of caulking in 313. Observed soiled toilet chair in room 506, spark unit spa bathroom, and toilet seat in room 702. Observed pitted faucet and sink drain with build-up in the carnation dining room. Observed calcium build-up on the back of the toilet in the bathroom of room 506. Observed toilet screw caps missing from the base of toilets in several bathrooms. Observed pink residue on the shower bed pad in 900 hallway spa and a rip on the bottom side of the shower bed pad in the 300 hallway spa bathroom. Observed caulking needed at the base of most toilets in bathrooms throughout. Observed soiled exterior of tub in spark center spa bathroom. Observed hair coming out of the shower wand in the 900 hallway spa bathroom. Observed and rip and cleaning needed on the bottom of the Geri chair in 100 hallway spa bathroom. **Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). **Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). **Keep all hand washing facilities clean and in good repair. 15A NCAC 18A .1312 (b)

#9 · Toilet rooms free of storage, hand wash signs posted −1

REPEAT Observed several rooms and bathrooms on back hallway that have been converted into storage rooms. **Toilet rooms shall not be used for storage. See rule .1312 (b).

#18 · Drinking utensils properly handled −2

REPEAT Observed several water pitchers throughout building with room number only. A better system needs to be put in place for labeling water pitchers. **Label all disposable water pitchers with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a).

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

REPEAT Observed knobs missing off of dresser with screws popping out in room 302. Observed stained mattress in rooms 200, 313, 800, 408 and a ripped mattress in room 702. Observed wheel chairs in need of cleaning in wheel chair storage room. Observed call bells in need of cleaning in the cracks and crevices of most rooms. **All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a). **Mattresses shall be kept clean, dry, and odor free. 15A NCAC 18A .1319 (a).

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

Observed debris on several beds throughout, underneath sheets. Observed stained pillow case in room 411, Observed a yellow stain on bed pad in room 408. **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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Dec 28, 2016 86 / 100 · 11 violations

Inspector comments: No Points: #43: Observed no thermometer in R 705. All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b). #11: Observed dirty utensils in hand wash sink in rehab. Except for the stipulations stated in rule .1312 (d), handwashing sinks shall only be used for handwashing. 15A NCAC 18A .1312 (d). Call for reinspection when ready. Put in service request with office assistant (980) 314-1620.

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

Repeat Non-Compliance: Observed poorly repaired ceilings in hallways and closets throughout facility. Observed damaged wall paper in hallways, some wallpaper had mold on backside. Observed damaged wall in R 14. Observed wall damage behind doors and lower areas of exterior walls. 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 tear in shower bed pad. Hair and debris below shower bed pad in shower rooms. Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed sinks that need cabinets below wiped out. Repair damaged backsplashes, R 102. Recaulk backsplashes where caulking missing, dining room. Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)

#9 · Toilet rooms free of storage, hand wash signs posted −1

Repeat non-compliance: Observed maintenance/general storage in converted resident rooms. Toilet rooms shall not be used for storage. See rule .1312 (b).

#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −1

Repeat non-compliance: Observed bedpans with no label in resident rooms throughout. Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).

#15 · Approved water supply, no cross-connections −2

Observed no backflow preventers on shower wands in baths, usually single occupancy rooms. Observed no backflow preventers on removable eye wash sprayers throughout. Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).

#18 · Drinking utensils properly handled −2

Repeat Non-Compliance: Observed disposable water pitchers labeled with room number only or not labeled at all throughout facility. Label all disposable water pitchers with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a).

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

Observed storage rooms need cleaning and organizing. Get rid of stuff not needed or in disrepair. Basins of garbage stashed in clean linen rooms and soiled utility rooms. **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 paper towels stored below hand sink in room in R 705. Personal items stored on floor in R 312 Unused specimen vials stored at hand sink in soiled utility room. ** 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 −2

Repeat Non-Compliance: Observed several damaged mattresses in resident rooms throughout facility. All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).

#33 · Linen changed when soiled. Soiled linen handled properly −2

Observed soiled linen carts not labeled as "soiled linen" throughout facility. Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b). Observed sheets on several resident beds stained or torn. Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).

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

Observed clean linen and chemical storage intermingled in clean linen room on service hall. Clean linen cart covers in disrepair throughout building. Hallway linen carts soiled, put onto cleaning schedule. **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).

#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −0.5

Observed used skin contact (razors, deodorant, etc.) items in general storage in shower rooms. Dispose of used items after use or return to patient's room after bath. ** Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).

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Apr 28, 2016 90 / 100 · 7 violations

Inspector comments: 5. Repeat non-complaince: Observed vent in activity room in 1000 hall collecting dust. Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). Improvement from previous inspection. 15. Repeat non-complaince: Observed removable eyewash stations throughout facility with no backflow preventers. Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d). Improvement from previous inspection. 14. Caregiver stated that disinfectant is left on toilets for less than 10 minutes. A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). 28. Observed patient contact items stored in box on floor in treatment nurse room. Observed storage of clothing in clean linen room, clothing co-mingled. Observed storage in restrooms in back hall unused rooms. All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a). 32. Observed one damaged mattress and two damaged pillows in room 905. 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 refrigerator light damaged in Spark Unit 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).

#1 · Floors easy to clean, no obstacles, drains where needed −2

Repeat non-complaince: Observed separation in floor tiles in nourishment room in arboretum. 105 bathroom floor damaged at threshold. Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b).

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

Repeat non-compliance: Observed walls damaged in hallways and resident rooms throughout facility. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.

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

Observed sink backsplashes throughout facility damaged, caulk damaged, cabinets damaged, cabinets missing backsplash, and hand sink basins collecting residue throughout facility. Observed showher bed collecting residue in 900 spa. Observed shoer curtains collecting residue in Spark Unit and 900 spa. Observed soiled hand towel in 900 spa. Toilet, handwashing, and bathing facilities must be conveniently located and readily accessible to residents and staff. 15A NCAC 18A .1312 (a).

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

Repeat non-complaince: Observed bed pan in spark unit not labeled. Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c). Improvement from previous inspection.

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

Repeat non-complaince: Observed several hand wash lavatories with no towles, one nourshment room one resdient room. Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d).

#18 · Drinking utensils properly handled −1

Repeat non-complaince: Observed one water pitcher with room number only. Label all disposable water pitchers with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a). Improvement from previous inspection.

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

Observed ice makers collecting residue throughout. Observed ice bucket in arboretum collecting pink residue on cart. Ice shall be handled, transported, stored, and dispensed in such a manner as to be protected against contamination. 15A NCAC 18A .1314 (b).

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Oct 21, 2015 84.5 / 100 · 12 violations

Inspector comments: 2. Observed debris collecting on floor around oxygen storage. Observed debris on floor in several storage rooms throughout facility. Observed bathroom floor collecting reisdue in 100 hall bath.Keep all flooring clean. 15A NCAC 18A .1309 (a).13. Observed hot water at 97.8 degrees in 100 hall bath hand sink.Maintain the hot water at all resident accessible hand washing sinks and bathing facilities within the temperature range of 100°F to 116°F. 15A NCAC 18A .1312 (e).15. Observed no backflow prevents on shower wands in baths throughout. Observed no backflow preventers on removable eye wash sprayers throughout. Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).16. Observed no complete backup water supply plan available.Observed an incomplete backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f).21. Observed dumpster side door open and trash collecting on ground infront of dumpster.All solid wastes containing food scraps or other decomposable materials shall, prior to disposal, be kept in leak-proof, non-absorbent containers, which shall be kept covered with tight fitting lids when filled or stored, or not in continual use. 15A NCAC 18A .1316 (a).24. Observed silverfish in resident room on SPARK unit.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).39. Observed food not labeled in nourishment refrigerator with resident name or date.All food and food supplies provided by an institution shall be from sources that comply with 15A NCAC 18A. 2600.44. Observed 5 gallon water container stored on floor, used for backup water supply.Containers of food shall be stored above the floor, on clean racks, dollies, slatted shelves, or other clean surfaces in such a manner as to be protected from splash or other contamination. 15A NCAC 18A .1323 (c).

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

Repeat non-compliance: Observed floor damaged in carnation dining room.Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b).

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

Observed stained ceilings in hallways and closets throughout facility. Observed damaged wall paper in hallways. Observed damage in 812, 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 dusty vents in bathrooms throughout facility.Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).

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

Repeat non-compliance: Observed damaged shower stretcher mat in 800 bath. Observed dirty shower stretchers, shower chairs, and shower stall walls in bathrooms throughout facility. Observed several toilet collecting residue in resident rooms. Observed one loose toilet seat in 800 hall. Observed toilets dirty in maintenance rooms, converted guest rooms.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).

#9 · Toilet rooms free of storage, hand wash signs posted −1

Repeat non-compliance: Observed maintenance storage in converted resident rooms.Toilet rooms shall not be used for storage. See rule .1312 (b).

#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −1

Repeat non-compliance: Observed bedpans with no label, or only room and bed number in resident rooms throughout.Observed dirty bed pans stored as clean in 304/306 restroom.Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).All bedpans/urinals/emesis basins shall be cleaned after each use. 15A NCAC 18A .1312 (c).

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

Observed no paper towels in 100 bath.Provide liquid soap and disposable towels at all hand washing sinks. 15A NCAC 18A .1312 (d).

#18 · Drinking utensils properly handled −1

Observed disposable water pitchers labeled with room number only.Label all disposable water pitchers with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a).

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

Observed ice chest accessible to residents on 700 hall.All ice machines and storage chests which are accessible to the residents and the public shall be automatic ice dispensing machines. 15A NCAC 18A .1313 (b).

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

Observed several damaged mattresses in resident rooms.All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).|

#33 · Linen changed when soiled. Soiled linen handled properly −2

Observed sheets on several resident beds stained and collecting debris. Observed soiled linen not covered in soiled room for laundry intake.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).

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

Observed residue collecting on refrigerators in nourishment rooms throughout.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).

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Apr 22, 2015 90 / 100 · 7 violations

Inspector comments: #1 Observed floor cracked in Carnation Dinning room and 800 hall. Keep all flooring in good repair for easy cleaning.#4 Observed 1 light that in need of replacement in resident room #703. Repair light. #23 Observed trash can labeled "Biohazard trash" without red bag. Ensure medical waste is properly disposed of in correct container. #24 Observed several ants found in clean utility room cabinet in Sparks wing. Ensure facility is free of pests.#32 Observed residue on mattress in room 1001. Keep mats in good repair. #35 Observed corner table in rehab room with rip present in corner surface. Observed bookshlelf in 900 hall activity room in need of repair. Shelf is pulling away and potentially about to fall. Furniture shall be kept in good repair. #36 Observed microwaves containing residue in need of cleaning in the following areas: Both Rehab gyms, 600 hall nourishment. Food service equipment shall be kept clean.#40 Observed 2 containers of ice cream stored in resident fridge. All other employee food was separate from resident food. -Observed back up water supply present with numbers supplied. Observed telephone number missing for back up water supply "source" water utlility. PET agreement to provide 10 gallons of water per patient a day was observed, but signed back in 2006. Ensure agreement is up to date. Ms. Vanessa Poindexter and Mr. Kevin Scruggs was present during inspeciton.

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

Repeat Non Compliance: Observed damaged walls and wall paper in resident rooms, activity rooms, laundry room, sparks unit, resident bathrooms and hall ways throughout facility. Observed pop corn ceiling peeling around vent in activity room at front of facility. **Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.

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

Repeat Non Compliance: Observed shower bed mat in disrepair located on 900 Hall and in rehab unit. Observed debris located under shower pad in rehab bathing facilityRepeat Non Compliance: Observed pink residue present on bathing facility shower curtains and on underside of shower chair in rehab bathing facility.**Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).

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

Repeat Non Compliance: Observed soiled utility carts stored in resident bathrooms and in bathing facility's. Areas included, but not limited to: Rehab bathing facility, Sparks bathing facility, and in 911. Observed garland stored in a soiled utility closet, and work tools and other storage in sparks soiled utility closet.**Toilet rooms shall not be used for storage. See rule .1312 (b).

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

Repeat Non Compliance: Observed bed pans not labeled in following areas: 808 1001, 604, with residue still in container. **Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).**All bedpans/urinals/emesis basins shall be cleaned after each use. 15A NCAC 18A .1312 (c).

#14 · Disinfectant accessible, properly used −2

Repeat Non Compliance: Observed disinfectant looked in storage cabinet in resident bathing facility on 900 hall, with disinfectant present in Spark bathroom but not being used. Cap was still present. **A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).

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

Repeat Non Compliance: Observed multiple storage areas throughout facility with overloaded resident items stacked together enabling proper cleaning. Organize items to facilitate easy cleaning. Repeat Non Compliance: Observed patient contact items stored on floor of central supply closet. Items included diapers, food bags, tissue paper. Observed boxes stored on floor at end of hall near kitchen. Shipment was received yesterday per Ms. Vanessa.Observed used hair brush stored with clean linen on 800 hall and resident nebulizer tube on floor in room 910. **Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a).**All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).

#33 · Linen changed when soiled. Soiled linen handled properly −2

Repeat Non Compliance: Observed stained comforter, linen, pillow case and or mattress pads in the following rooms: 808, 911, 910, 604, 403, 703.Observed soiled hand rags stored underneath cabinet found in Carnation Dinning room. **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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Jul 22, 2014 90 / 100 · 10 violations

Inspector comments: . #4 Observed lighting in resident bathrooms throughout facility not providing sufficient light only reaching 4 ft candles. Higher wattage light bulbs shall be replaced to provide adequat lighting. **All areas in which food is prepared, or in which utensils are washed, shall be provided with at least 50 foot-candles of light on food preparation work levels and at utensil washing work levels. 15A NCAC 18A .1311 (a) and 15A NCAC 18A .2630 (a) and (b). #10 Observed bed pans not labeled in rooms 315, 500. Labeling required. **Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).#9 Observed soiled uitlity cart stored in residents bathroom. Cart shall be moved and placed in separate room. **Toilet rooms shall not be used for storage. See rule .1312 (b).#35 Observed diaper on cart in therapy hall spa on floor. Patient contact items shall be stored off floor to prevent contamination. **Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).**Mr. James was present during inspection

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

Repeat Non-Compliance: Observed floors in need of general cleaning and repairing cracks in dinning hall, resident rooms and mis. rooms throughout. **Keep all flooring clean. 15A NCAC 18A .1309 (a).

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

Repeat Non Compliance: Walls to have dents, build up residue in bathrooms, blood stain in room 804, peeling wall paper, holes in need or repatching /repairing/cleaning. Ceilings to have cracked surfaces throughout, with a leak in corner of mens staff restroom. All floors walls and ceilings in need of general attention to cleanliness. **Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.

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

Repeat Non-Compliance: Observed soiled shower chairs in spa's throughout in need of adequate cleaning. Observed shower pad in therapy hall spa torn in multiple places in need of repair. Repeat Non-Compliance: Obserrved shower curtains throughout spas with residue build up on bottom half of curtains in need of cleaning. Observed green linen storage container soiled on second shelf in need of cleaning. Observed broken plastic chair in therapy bathroom in need of repair or replaced. **Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).Repeate Non-Compliance: Observed toilet chair stained in room 910, toilet seat in need of repair in 900 spa, loose toilet seat in room 412** Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).

#13 · Lavatory and bathing hot water between 100 and 116 F −1

Observed hot water reaching over 116 F limit at sinks and bathrooms throughout facility. Temperatures ranged from 118 - 120 F. Water shall be tempered down to 100 - 116 F range. **Maintain the hot water at all resident accessible handwashing sinks and bathing facilities within the temperature range of 100°F to 116°F. 15A NCAC 18A .1312 (e).

#14 · Disinfectant accessible, properly used −1

Observed multiple disinfectants locked in cabinets, not accessible throughout facility. Where residents are bathing, disifectant shall be accessible at all times. **A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).

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

Observed mulitple storage rooms throughout facility with overloaded resident items stacked together enabling proper cleaning. Items shall be orgainized in fashion for proper cleaning process. **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 items stored under sink in gym therapy room in need of relocation. **Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a).Observed patient contact items stored on floor throughout facility in need of placing at minimum height requirement. **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 −1

Repeat Non-Compliance: Observed med cart collecting residue in drawer. Improvement made from last inspection. **Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).

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

Repeat Non-Compliance: Observed several torn, rippend, mattresses in rooms 804, 910, 500 in need of replacement. Repeat Non-Compliance: Observed ripped pillows throughout facility in need of replacement. **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 heavy staining of comforters, linens, pillow cases, mattress pads, throughout facility that need to be washed when soiled, or replaced. **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 items brought from home stored in front entrance nourishment room unlabeled. **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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Nov 4, 2013 91 / 100 · 6 violations

Inspector comments: 2. Observed stain (that appeared to be urine) on the floor under the bed in room 1014.Keep all flooring clean. 15A NCAC 18A .1309 (a). 9. Observed Geri chair used to transport resident from the bed to the dinning area stored in the restroom of 204.Toilet rooms shall not be used for storage. See rule .1312 (b).Mr. James, Mr. Brannon, & Ms. Kathy present during the inspection.

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

-Repeat Non-Compliance: Observed wall damage (wallpaper and/or FRP) in bedrooms, restrooms, common areas, etc.-Observed water stained ceilings in several rooms. Per James, head custodian, there has been a sprinkler pressure issue in the kitchen which was leading to the water damage/stains.-Observed hole in the wall behind the door in the linen room on the 400 hall.-Observed crack in the ceiling in the shower room on the Rehab hall.-Observed cobwebs collecting in the Rose Dining Room.Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.

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

Repeat Non-Compliance: Observed soiled toilet seats (top and underneath) in the resident's restrooms.Repeat Non-Compliance: Observed debris on shower stretcher that was stored as clean on the Rehab hall.Repeat Non-Compliance: Observed pink build up on the shower chair in the 400 hall.Observed pink build up on several shower curtains throughout.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).

#13 · Lavatory and bathing hot water between 100 and 116 F −1

Observed water on the 100, 400, 700, & 900 halls below 100F. Per James, head custodian, this is due to a water pressure issue with the sprinkle system in the kitchen.Maintain the hot water at all resident accessible handwashing sinks and bathing facilities within the temperature range of 100°F to 116°F. 15A NCAC 18A .1312 (e).

#14 · Disinfectant accessible, properly used −1

Repeat Non-Compliance: Per the cleaning staff, the shower equipment is cleaned by spraying the disinfectant and wiping it down immediately afterwards.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). Ensure the directions are followed for proper disinfecting of equipment.

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

Repeat Non-Compliance: Observed med cart drawers collecting residue in 2 of the 3 inspected.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

-Repeat Non-Compliance: Observed dividing curtains in several rooms collecting residue throughout.-Repeat Non-Compliance: Observed damaged mattresses in several rooms throughout. (room 910 had what appeared to be urine collecting on the bottom side of the mattress as well as inside the rips.-Observed ripped pillows in several rooms.-Observed night stands (400) and vanities (in 412 & 405) with worn and or separating facing.-Observed damaged counter at the shampoo bowl (near the floor) in the beauty shop.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).

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Source: Mecklenburg County Public Health – Environmental Health public inspection portal (search for “UNIVERSITY PLACE NURSING AND REHABILITATION CENTER” or State ID 2060400060). Inspection type (routine vs. follow-up) is not published in the county's data.