97/ 100
TERRABELLA LITTLE AVENUE
7745 LITTLE AV, Charlotte, NC 28226
Rest/Nursing Homes · NC permit/State ID 2060400085
Latest result97 / 100
Last inspectedJan 12, 2026
Inspections on record23
On record sinceNov 11, 2013
Score history
Nov 11, 2013Higher is betterJan 12, 2026
Inspections & violations
Jan 12, 2026 97 / 100 · 3 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 scuffed walls in various areas throughout facility. Repair.
#5 · Ventilation equipment clean, good repair −1
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed heavy dust buildup in a/c vents in room 113. Keep clean. REPEAT
#7 · Facilities provided, accessible, clean, good repair −1
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed loose toilet seat in room 104. Tighten. REPEAT *Points not escalated due to improvements in toilets and bathing facilities from previous inspection*
Jul 16, 2025 95.5 / 100 · 6 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free
1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair. Observed cracked/damaged floor tiles in laundry room in memory care. Repair.
#2 · Walls and ceilings clean, good repair
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. Observed peeling/chipping wall in memory care laundry room with multiple holes in wall. Repair.
#5 · Ventilation equipment clean, good repair −0.5
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed several bathroom vents in resident rooms with dust buildup. Keep ventilation equipment clean. REPEAT
#7 · Facilities provided, accessible, clean, good repair −1
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed shower seat in need of cleaning in room 117 MC. Observed loose toilet seats in rooms 117 MC and 127 AL. Observed peeling shower seat in need of replacement and shower floor in need of cleaning in room 127.
#16 · Hot water between 105°F and 116°F −3
.1313 (d) Institutions shall provide water heating facilities. Hot and cold running water under pressure shall be provided to carry out all operations. Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities. Observed hot water at 119F in room 117, and 117F in room 121 and 120. Ensure hot water is between 105-116 at handwashing and bathing facilities. REPEAT
#28 · No pest presence; effective pest control measures
.1317 (a) Pests shall not be present in an institution's building or buildings. Observed live roach-like bug in room 120. Observed silverfish bug on 2nd floor ceiling. Observed a 1-2 gnats/flies throughout building.
Jan 7, 2025 98 / 100 · 5 violations
#5 · Ventilation equipment clean, good repair
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed filters missing on A/C unit in 126. Needs repair.
#10 · Handwashing facilities properly located and equipped
.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices. Observed no papertowels at handsink in memory care activity area. Needs papertowels.
#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 at handsinks over 116F in 113, 230, and 231. Hot water for handwashing and bathing shall be 105-116F.
#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 facility had parts of the backup water supply plan for food service and cleaning. Facility needs complete plan. Facilty has county backup water supply check list and handout information. EHS advised facility to fill out check list.
#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 spill in memory care activity area freezer needs cleaning.
Jul 8, 2024 96.5 / 100 · 3 violations
#2 · Walls and ceilings clean, good repair −2
REPEAT
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. Observed holes and damaged areas in wall inside common area in need of repair; Observed hole being created by door knob of bathroom door in need of repair inside resident room #208
#7 · Facilities provided, accessible, clean, good repair −1
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 several toilet seats very loose in need of repair / tightening throughout facility.
#28 · No pest presence; effective pest control measures −0.5
.1317 (a) Pests shall not be present in an institution's building or buildings. Observed numerous I’ve ants inside resident room #216 in need of immediate attention.
Apr 11, 2024 95.5 / 100 · 8 violations
Inspector comments: Sink leaking in bathroom of room 121. Water to the facility has been shut off due to leaking pipe and plumber was onsite during inspection repairing pipe.
#2 · Walls and ceilings clean, good repair
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. Observed multiple walls throughout the facility, such as memory care common area, room 128, damaged or scuffed in need of repair and/or repainting.
#5 · Ventilation equipment clean, good repair
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed air vent in memory care common area with heavy debris buildup, as well as multiple private resident bathrooms in memory care with dusty bathroom vent fans.
#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 toilets in multiple private resident bathrooms soiled and in need of cleaning. Observed a handful of toilets with loose seat cover in need of repair. Repeat.
#30 · Medication carts clean; sharps containers attached; food, utensils, medication and medication dispensers properly handled
.1318 (a) Food, utensils, medications, and equipment used on medication carts shall be kept clean. Observed medication cart in memory care area with patient cups over stacked, exposing the lips to possible contamination. Informed PIC to either keep smaller stacks of cups or keep covered from contamination.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair
.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair. Observed chair, pillow, and mattress in room 126 soiled or stained. Observed stained box spring in 125.
#33 · Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled −0.5
.1319 (b) A resident's bed linens shall be changed when no longer clean. Observed chair, pillow, and mattress cover in room 126 soiled or stained. Observed more stained sheets in room 121, soiled mattress cover in 127, and soiled linens in 210.
#38 · Food service equipment and utensils clean, good repair −1
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed refrigerators in rooms 109, 210, 208, second floor common room, and memory care common room with food debris buildup and in need of cleaning. Observed microwave in room 210 and second floor common room soiled with food debris and in need of cleaning. Repeat.
#45 · Hot and cold holding equipment provided; thermometers provided, accurate −1
.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 refrigerator in room 227 and second floor common room without thermometers. Observed refrigerators in rooms 210 and 208 with ambient temperature of 60 degrees. Repeat.
Sep 21, 2023 97 / 100 · 9 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −1
1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair. Observed flooring need to be cleaned in memory care unit closet, room 218, 212, 121, kitchen closet upstairs.
#7 · Facilities provided, accessible, clean, good repair −1
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed shower tub needs to be cleaned in room 211, loose toilet seat needs to be repaired in room 206, damaged toilet seat needs to be replaced in room 230, toilet and or hand sink need cleaning in room 218, 212, AL restroom. Observed slow draining at the common area sink in room 218, need repair.
#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 men’s restroom main hallway, memory care restroom, AL restroom need hand washing sign posted. Hand washing signs provided at the time of inspection.
#10 · Handwashing facilities properly located and equipped
.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices. Observed salon is missing soap for hand washing. Ensure to provide all hand washing supplies at all hand sinks at all time.
#16 · Hot water between 105°F and 116°F
.1313 (d) Institutions shall provide water heating facilities. Hot and cold running water under pressure shall be provided to carry out all operations. Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities. Observed water temperature at the hand sink at some part of the building where it is closed to hot water heater, the temperature was above the required range from 2-3 degrees. The maintenance will adjust the water temperature and keep within the range of 105F to 116F.
#17 · Back-up water supply plan available and complete
.1313 (e) The institution shall have a written plan to obtain a backup water supply in the event that the institution's primary water supply is interrupted for more than four consecutive hours. The written plan shall identify a backup water supply or alternate source of water that provides two liters of potable water per day per resident and institution employee for drinking and potable water for food preparation, hand washing, bathing, cleaning, dishwashing, laundry, and disposal of bodily waste. This may include a plan for relocating residents to a facility with a water supply that satisfies Paragraph (a) of this Rule. If an institution's primary water supply or backup water supply becomes unsafe for human consumption, then the water sources within the institution, such as sink faucets, shall be labeled or hooded to prevent their use, and the administrator shall provide potable water for use by the institution's residents and employees. Observed facilities with incomplete water back up supply plan. EHS emailed administrator the checklist of the plan, and discussed what required at the time of inspection. The administrator will put the plan ready by next inspection.
#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 microwave in memory care dining room need to be cleaned and keep clean.
#42 · Food and food supplies from approved sources; properly stored and handled
.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. Observed boxes of can foods and boxes of single service articles stored on the floor in the kitchen storage upstairs. Maintenance and staff is currently working on getting items up and get rid of some items. Ensure to keep all items off the floor at least 6 inches or above to prevent cross contamination.
#45 · Hot and cold holding equipment provided; thermometers provided, accurate −0.5
.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 refrigerator in memory care unit need the thermometer for temperature indication.
Dec 12, 2022 98 / 100 · 2 violations
Inspector comments: Memory Care unit is on Covid lockdown. Restricted at this time. Facility is currently undergoing renovations throughout. Thomas Lowery present during inspection.
#7 · Facilities provided, accessible, clean, good repair −1
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed stains on toilets in rooms 202, 205, and 227.
#26 · Premises properly maintained −1
.1316 (d) An institution's exterior premises, including parking lots, lawns, and walkways, and interior premises within the institution's building or buildings, shall be kept free of garbage, solid waste, yard trash, and pest harborages. Observed trash bags and trash on ground near dumpsters.
May 11, 2022 97 / 100 · 2 violations
Inspector comments: No points deducted:#32–Observed stains on 1 chair in Memory care lounge area. Inspection completed with Tara Benson.
#2 · Floors clean, carpet clean, dry, odor free −1
Observed carpet stains on floor near chairs in room 218, No escalation in points due to improvement seen.
#8 · Facilities conveniently located, clean and in good repair −2
Observed rust on undercarriage of toilet seat and in hand sink in room 218. Observed rust around sink drain in room 210. Observed pink stain in toilet in room 128.
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
Nov 8, 2021 95 / 100 · 5 violations
Inspector comments: Noticed name change on sign near front door. Spoke with ED, Tara, and was told that owner is the same, but different management. Business license hasn't been changed as of today. Tara will reach out once all paperwork is complete.
#2 · Floors clean, carpet clean, dry, odor free −1
Observed red and brown stains in carpet in room 226.
Keep all flooring clean. 15A NCAC 18A .1309 (a).
#3 · Walls and ceilings cleanable, clean, good repair −1
Observed walls peeling in laundry room in Memory Care. Touch up paint.
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 dust on ac filters and black residue/build up on vents in room 111.
Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).
#8 · Facilities conveniently located, clean and in good repair −1
Observed damage on hand sink behind faucet in room 124.
Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
#28 · Adequate storage, area clean, items properly stored −1
Observed push walkers stored in shower in rooms 113 and 124. Discontinue storing items in shower unless used for bathing purposes.
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).
May 3, 2021 93.5 / 100 · 6 violations
Inspector comments: No Points Deducted:
4. Observed light in the 2nd floor biohazard storage room not working.
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).
15. Observed no back flow preventer on the shower wand in 105.
Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).
#3 · Walls and ceilings cleanable, clean, good repair −1
Repeat: Points Not Increased due to improvement.
Observed a hole in the wall in the memory care dining area.
Observed walls need cleaning in the restroom of 121.
#8 · Facilities conveniently located, clean and in good repair −2
Repeat:
Observed pink buildup in the bottom of the shower in 116.
Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
Observed loose toilet seat in 116 and 1st floor hall restroom.
Observed stained toilet seat in 121, and stains on the outside of the toilet bowl in the 1st floor hall restroom.
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
#28 · Adequate storage, area clean, items properly stored −0.5
Observed a pile of clothes, pillows, and/or bedding stored in the floor in the closet in rooms 121 and116.
Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Observed stains in med cart drawers.
Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).
#33 · Linen changed when soiled. Soiled linen handled properly −1
Observed the comforter, sheets, and mattress cover stained in 116.
Observed stained sheets in 230.
Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).
#36 · Approved utensils and equipment, cleaned and sanitized −1
Observed debris in the microwaves in 106 and the Memory care dining room.
Non-food contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. See rule .1320 (c).
Dec 3, 2020 92.5 / 100 · 6 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 wall damage in employee bathroom area.
#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 rusted shower floor, non-slip mat slimy, room 109. Toilet chair with cloth taped to bar, room 103.
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed toilet needs cleaning room. Observed both employee bathrooms broken. Need repair ASAP.
#22 · Solid waste disposed of frequently, no insect breeding or nuisance −1
All solid wastes shall be disposed of with sufficient frequency and in such a manner as to prevent insect breeding or public health nuisances. 15A NCAC 18A .1316 (d). Observed several areas with drain flies.
#26 · Premises clean, no breeding places or rodent harborage −2
The premises shall be kept neat, clean, and free of litter. 15A NCAC 18A .1317 (c). Observed dumpster missing drain plug. Animal pulled out garbage.
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c). Observed soiled baggies and drawer of med cart. When baggies holding single service soiled, replace
#43 · Food storage units with thermometers, maintain temperatures −0.5
All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b). Observed some refrigerators without thermometers in rooms. One refrigerator isn't sealing room 209.
Nov 20, 2019 90 / 100 · 7 violations
Inspector comments: No Points Deducted:
1. Observed items stored on the floor in the activity room upstairs behind the counter. Floor can not be seen. Organize and clean.
Floors shall be free of obstacles to cleaning. 15A NCAC 18A .1309 (a).
5. Observed dust buildup on the filters in the laundry and mop rooms. Clean
Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).
13. Observed water at 121F in room 218, 122F in the therapy restroom, and 118F in the MC dining room & 115. Repair.
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).
REMINDER: Ensure score card is visible as permitted by law.
#8 · Facilities conveniently located, clean and in good repair −2
-REPEAT: Observed stained toilet seat in room 201, rusted toilet riser in room 218, and very loose toilet seat in room 208.
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
-Observed clogged sinks in rooms 120 and 201. Repair.
Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
#9 · Toilet rooms free of storage, hand wash signs posted −0.5
REPEAT: Observed wheelchairs stored in the therapy restroom. Follow the rule below.
Toilet rooms shall not be used for storage. See rule .1312 (b).
#26 · Premises clean, no breeding places or rodent harborage −2
REPEAT: Observed ants in rooms 120, 128, and 218. Provide pest control.
There shall be no fly or mosquito breeding places, rodent harborages, or undrained areas on the premises. 15A NCAC 18A .1317 (c).
#28 · Adequate storage, area clean, items properly stored −1
REPEAT: Observed boxes of ABD pads, gloves, and paper towels stored on the floor: Housekeeping closet, Nurse's storage closet.
All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −2
REPEAT: Observed stains on the mattress cover and/or sheets in room 218,128, 201, 208, & 231, hole in the sheets in rooms 120 and 115.
All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −0.5
REPEAT: Observed hair in multiple of the brushes in the beauty salon. Follow the rule below.
Patient contact items that become contaminated during use shall be cleaned and disinfected after each use. 15A NCAC 18A .1319 (c).
#36 · Approved utensils and equipment, cleaned and sanitized −2
REPEAT: Observed buildup inside of the refrigerators in rooms 109 and 201, in the memory care dining room refrigerator, and in the microwave in room 231. Clean.
Non-food contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. See rule .1320 (c).
Apr 25, 2019 94.5 / 100 · 6 violations
Inspector comments: 2) REPEAT VIOLATION Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed stained carpets in stair wells and in therapy room. Observed vacuuming needed in file storage room.
Previous violation corrected.
9) Toilet rooms shall not be used for storage. See rule .1312 (b). Observed mattresses stored in therapy room bathroom.
33) Soiled linen shall be placed in a covered container or bag at the point of use and stored and handled so as to contain and minimize aerosolization of and exposure to any waste products. 15A NCAC 18A .1319 (b). Observed soiled linen placed in open hamper in 132. Clean linen in good repair shall be provided for each individual and changed when soiled. 15A NCAC 18A .1319(b) Observed stained cover in room 132. REPEAT VIOLATION Improvement from previous inspection.
35) Patient contact items that become contaminated during use shall be cleaned and disinfected after each use. 15A NCAC 18A .1319 (c). Through discussion with beautician, hair clips are only rinsed in hot water for cleaning. Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c). Observed comingled patient contact items (brushes) in room 132.
43) All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b). Observed broken thermometer in 101 refrigerator. Observed no thermometer in room 104.
All refrigerators shall maintain a temperature of 45°F or below. 15A NCAC 18A .1323 (b). Observed air temperature in refrigerator at 58F in room 104. Only gatorade drinks were in the refrigerator.
NOTE: Building grade card was covered by "activities for the week" display. Ensure grade cards remain visible at all times as required by law.
#3 · Walls and ceilings cleanable, clean, good repair −1
REPEAT VIOLATION Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.Observed wall damage in 2nd floor storage room, bathroom by nursing storage, 226 bathroom, and 101 closet door. Observed touch up paint needed in housekeeping on 2nd floor, biohazard room, therapy room baseboards, laundry room walls, community mens bathroom, and memory care med supply storage.
#8 · Facilities conveniently located, clean and in good repair −1
REPEAT VIOLATION Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed pink build up on shower heads in room 211, 226, 229, and 115. Observed stained shower curtain and build up on shower seat in 101.
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed peeling/chipping on inside of toilet in 101, 226 and 229. Observed broken/missing toilet paper holder in 115. Observed toilet riser loose in 206 and 104. Observed flush handle broken in 104. Observed strong odors in 1st floor womens community bathroom and 229 bathroom.
#26 · Premises clean, no breeding places or rodent harborage −1
There shall be no fly or mosquito breeding places, rodent harborages, or undrained areas on the premises. 15A NCAC 18A .1317 (c). Observed standing water in buckets in main courtyard. Observed gnats in 226 and therapy room. Observed door to outside left propped open in memory care area with no fly fan or barrier to keep pests from entering building.
#28 · Adequate storage, area clean, items properly stored −0.5
REPEAT VIOLATION All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). Observed briefs stored on floor throughout resident rooms including 211, 206, 132, and med supply storage in memory care. Observed boxes of plastic cups on floor in nursing storage. Observed catheter kit stored under medication disposal chemical in nursing storage.
Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a). Observed briefs stored under sink in room 101.
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
REPEAT VIOLATION All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a). Observed stained chairs in memory care day room and 132. Observed stained pillows throughout resident rooms in facility including in 206, 229, and 132. Observed debris under couch and chair cushions throughout living rooms and in main hallway on first floor. Observed minor wear on arms and backs of chairs in activity room. Observed debris and dust build up on window sill in 101. Observed jam spilled in drawer in 101. Observed heavily rusted washing machines.
#36 · Approved utensils and equipment, cleaned and sanitized −1
Non-food contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. See rule .1320 (c). Observed build up on inside of therapy room refrigerator and memory care refrigerator.
Oct 1, 2018 93.5 / 100 · 5 violations
Inspector comments: NO POINTS WERE TAKEN FOR THE FOLLOWING:
#1 - Observed transitional moulding missing from entry to restroom of memory care. **Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b).
#2 - Observed stained carpet in room 226, 103, and in stairwell. Observed cleaning needed on the floor in bathroom of room 216, on the floor in memory care dining/activity room, and behind toilet in room 132.
**Keep all flooring clean. 15A NCAC 18A .1309 (a).
#3 - Observed caulking needed on top of shower in room 216 and 132. Observed wall and baseboard to be soiled in room 132. **Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#11 - Observed maintenance director state that hands are washed in beauty salon hair washing sink. Facility was built prior to 2003. EHS advised PIC to have caregivers use hand sanitizer in lieu of hand washing in beauty salon. **Except for the stipulations stated in rule .1312 (d), hand washing sinks shall only be used for hand washing. 15A NCAC 18A .1312 (d).
#27 - Observed pet records to be expired for pony that visits facility. Obtain updated records.
**Maintain adequate vet records for all animals. 15A NCAC 18A .1317 (f).
#32 - Observed debris left in mattress of room 132. Observed improvement. **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 - Observed stained pillow case, mattress cover, and stained chair pad in room 116. Observed stained pillow case and sheets in room 132. Observed mattress cover with debris in room 132. **Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).
#8 · Facilities conveniently located, clean and in good repair −2
REPEAT Observed cleaning needed on underside of toilet chair in room 216 and 103. Observed toilet in need of cleaning in 103 and in restroom of memory care. Observed pink build-up on shower floor in room 216.
**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).
#16 · Quantitiy and hot water sufficient, backup water supply plan −1
REPEAT Observed no backup water supply plan on site. Checklist emailed.
**Observed no backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f).
#28 · Adequate storage, area clean, items properly stored −0.5
REPEAT Observed single-service cups being stored on floor in upstairs nurses closet. Observed briefs being stored on the floor in room 216. Observed toilet paper and paper towels being stored on shelf under engine oil in housekeeping closet of first floor.
**All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
#36 · Approved utensils and equipment, cleaned and sanitized −1
REPEAT Observed microwave in need of cleaning in memory care dining room. Observed improvement.
**All kitchenware and food contact surfaces of equipment, exclusive or cooking surfaces of equipment, used in preparation or serving of food or drink, and all food storage utensils, shall be cleaned after each use. 15A NCAC 18A .1320 (c).
#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 yogurt in refrigerator of room 216 at 49F thermometer read 49F. Observed refrigerator in room 211 at 56F with yogurt. Check thermometers daily.
**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).
Feb 5, 2018 94 / 100 · 4 violations
Inspector comments: No points deducted Today:
9. Observed wheelchairs and/or walkers stored in the Therapy room restroom as well as the restroom in room 125 (MC). Ensure to follow the rule below.
Toilet rooms shall not be used for storage. See rule .1312 (b).
16. Observed an incomplete backup water supply plan. Checklist emailed again.
Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f).
28. Observed depends stored on the closet floor in 216.
All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
Mr. Carlos present during the inspection.
#8 · Facilities conveniently located, clean and in good repair −2
-Repeat: Observed several bedrooms and the Therapy room's restroom with soiled toilet seats/risers (top and/or underneath). Clean.
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
-Observed black buildup on the bottom of the shower curtain in room 202.
Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Repeat: Observed one of the med carts with buildup in the drawers (improvement). Clean.
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
-Observed what appeared to be vomit under a couch cushion in the common area- MC unit.
-Observed the finish wearing off on the tables in the Activity room (2nd floor).
-Observed pillow, mattress cover, and/or mattress stains in rooms 111 and 208.
-Observed the drawers collecting residue in the dining/common area of the MC Unit.
All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
#36 · Approved utensils and equipment, cleaned and sanitized −2
Repeats:
-Observed heavy buildup (butter and crumbs) in the popcorn machine in the activity room. Clean to prevent any possible vermin
attraction.
-Observed microwaves with debris and residue in the MC dining room, therapy room, and room 111.
All kitchenware and food contact surfaces of equipment, exclusive or cooking surfaces of equipment, used in preparation or serving of food or drink, and all food storage utensils, shall be cleaned after each use. 15A NCAC 18A .1320 (c).
Jul 13, 2017 94.5 / 100 · 5 violations
Inspector comments: No Points Deducted:
2. -Observed urine on the floor in front of the toilet & stains on the carpet by the bed in MC room 105.
Keep all flooring clean. 15A NCAC 18A .1309 (a).
-Observed a urine smell in the MC unit. Extract carpet often.
All carpet shall be kept odor free. 15A NCAC 18A .1309 (a).
28. Observed depends stored on the closet floor in 214.
All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
32. Observed residue under the sink cabinet and on the cabinet doors in Activity room. Clean.
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).
39. Observed a rotten orange and moldy berries in the refrigerator in room 232. CDI- Discarded.
All food and food supplies shall be clean, free from spoilage, free from adulteration and misbranding, and safe for human consumption. 15A NCAC 18A .1321 (a).
#8 · Facilities conveniently located, clean and in good repair −2
Repeats:
-Observed several rooms and public hall restroom with soiled toilet seats/risers (top and/or underneath). Clean.
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
-Observed a few shower heads in need of cleaning.
-Observed buildup in the bottom of the shower in the Therapy room. Keep clean even though it is not used for washing.
Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
#16 · Quantitiy and hot water sufficient, backup water supply plan −1
No backup water supply/emergency water supply plan present. Emailed the checklist.
Observed no backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Observed the med carts collecting residue in the bottom of the drawers. Clean all.
Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).
#36 · Approved utensils and equipment, cleaned and sanitized −1
-Observed heavy buildup (butter and crumbs) in the popcorn machine in the activity room. Clean to prevent any possible vermin attraction.
-Observed the microwave with debris and residue in the MC dining room.
All kitchenware and food contact surfaces of equipment, exclusive or cooking surfaces of equipment, used in preparation or serving of food or drink, and all food storage utensils, shall be cleaned after each use. 15A NCAC 18A .1320 (c).
#43 · Food storage units with thermometers, maintain temperatures −0.5
Repeat: Observed no thermometer in the refrigerator in room 127, and the redline broken in the thermometers in the MC dining room and room 232.
All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b).
Feb 23, 2017 94.5 / 100 · 5 violations
Inspector comments: .#2 - Observed strong odor throughout memory care. Carpets may need a deep cleaning to reduce odor. All carpet shall be kept odor free. 15A NCAC 18A .1309 (a).
#10 - Observed bedpan in bathroom of room 118 in memory care that was not labeled. Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).
#11 - Observed cup and brown discoloration in sink of memory care sitting area. Ensure sink is not used as a dump sink. Except for the stipulations stated in rule .1312 (d), hand washing sinks shall only be used for hand washing. 15A NCAC 18A .1312 (d).
#13 - Observed hot water at temperatures as high as 121F in bathroom of room 214. 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 device present in mop sink of 100 hall laundry room in memory care. Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).
#26 - Observed sink hole in the back courtyard. Ensure hole gets filled in. The premises shall be kept neat, clean, and free of litter. 15A NCAC 18A .1317 (c).
#28 - Observed bathroom in Health Lifestyles Director room being used as a 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).
#34 - Observed cleaning needed in laundry machines throughout the facility. Laundry areas and equipment shall be kept clean. 15A NCAC 18A .1319 (b) and .1312 (a).
#35 - Observed hair built-up in electric razor in beauty salon. Patient contact items that become contaminated during use shall be cleaned and disinfected after each use. 15A NCAC 18A .1319 (c).
#43 - Observed missing thermometer refrigerator of room 102. All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b).
Inspection led by Savannah Parker accompanied by Shawn Blackmon.
#3 · Walls and ceilings cleanable, clean, good repair −1
Observed cleaning needed on walls and a hole in the wall behind the door in room 118 of memory care. Observed damaged ceiling needing repair in room 214.
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 cleaning needed in most toilets, and toilet chairs throughout the facility. Observed cleaning or replacement needed on several plastic shower curtains. Observed tightening needed on toilet seat in the bathroom of room 132. Observed urine left in urinal on sink counter in the bathroom of room 226. Observed cleaning needed on the bottoms of several shower chairs.
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).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed major cleaning needed in the bottom of furniture, mainly couches in the memory care sitting area and lobby areas. Observed missing drawer in the bathroom of room 126 in memory care.
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 debris in bed of room 214. Observed soiled linens needing to be changed throughout memory care.
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 food items in memory care refrigerator without dates on them. Observed several food items in activity kitchen without names or dates. Ensure name and date is labeled on all resident personal food items.
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).
Jun 22, 2016 93.5 / 100 · 5 violations
#8 · Facilities conveniently located, clean and in good repair −1
-Observed a heavy amount of pink and black growth on the door and the gasket of the washer: MC. (Allowing the washer to air dry may help lessen the growth). -Observed the glass on the door cracked on the top dryer. Repair. *Laundry facilities shall be kept clean and in good repair. See rule .1312 (a).
-Observed pink buildup on the shower wand's back flow preventer in 231. -Observed the floor of the shower in the Therapy room with black and pink buildup. -Observed pink on the shower curtains in 202 & 111. *Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
-Observed a loose toilet seat in 220.
*Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
#9 · Toilet rooms free of storage, hand wash signs posted −0.5
Repeat: Observed a room used for storage on the 2nd floor by room 232 with a toilet still in the room. If room is to used as storage, all plumbing fixtures shall be removed and capped off. (This item was general commented on the last inspection).
Toilet rooms shall not be used for storage. See rule .1312 (b).
#28 · Adequate storage, area clean, items properly stored −1
-Repeat: Observed boxes of bed pads, single service cups, and toilet "catch pans" stored on the floor in the Nurse's Storage closet.
All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
-Observed tooth brushes, wash cloths, etc stored under sinks in 220.
Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a).
Report emailed to mposse@elmcroft.com & aerrafi@elmcroft.com
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −2
-Repeat Non-Compliance: Observed the bottom of the vanities in the salon with water damage.
-Observed the couch with stains in 225. Clean.
-Observed the shelves in the refrigerator collecting residue in 111.
-Observed the mattress covers soiled and/or torn in 202 and 211.
-Observed stains on pillows in room 111 and 225.
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).
#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 all items in the MC refrigerator at 56-58F (butters, milk, opened juices). All items were discarded. DO NOT USE THIS REFRIGERATOR FOR POTENTIALLY HAZARDOUS ITEMS UNTIL IT IS REPAIRED AND READING 45F OR BELOW.
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).
Oct 21, 2015 91 / 100 · 7 violations
Inspector comments: 8. -Observed rust forming on the washing machine.Laundry facilities shall be kept clean and in good repair. See rule .1312 (a).-Observed broken toilet chair in 128.Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). 9. Observed a room used for storage on the 2nd floor by room 232 with a toilet still in the room. If room is to used as storage, all plumbing fixtures shall be removed and capped off.Toilet rooms shall not be used for storage. See rule .1312 (b). 14. Observed an unlabeled bottle on the housekeeping cart. Per employee, the chemical was disinfectant, but when tested was at 0ppm quat.Observed no quat test strips. Provide.Where disinfectants are mixed on site, the concentration of the mix shall be assured by use of a metering pump, measuring device or chemical test kit. 15A NCAC 18A .1312 (f).33. Observed soiled sheets in 216 and 113, and comforter in 125.Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). 36. -Observed the refrigerator gasket in room 216 moldy.-Observed the microwave and dining room refrigerator collecting debris and residue.- MCNon-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).report emailed to mposse@elmcroft.com
#3 · Walls and ceilings cleanable, clean, good repair −1
-Repeat Non-Compliance: Observed water stains on ceiling in upstairs hallway.-Observed the restroom cove base separating from the wall in room 227.-Observed holes in the wall in the MC dining room.-Observed the frame around the MC hall restroom broken. Repair.Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#16 · Quantitiy and hot water sufficient, backup water supply plan −1
Repeat Non-Compliance: Observed no backup water supply plan. Guideline form emailed.Observed no backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f).
#24 · Vermine excluded −1.5
Observed a heavy presence of ants in room 125 coming out of the wall AC unit and on the base boards, and gnats in MC dining room.Effective measures shall be taken to keep flies, rodents, cockroaches, and other vermin out of the establishment and to prevent their breeding or presence on the premises. 15A NCAC 18A .1317 (a).
#28 · Adequate storage, area clean, items properly stored −1
Repeat Non-Compliance: -Observed briefs stored on the floor in the restrooms and closets in multiple rooms.All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).-Observed briefs stored under the handsink pipe in 125. Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a).-Observed the cabinets and rolling cart in the MC unit dining room in need of cleaning.Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −2
Repeat Non-Compliance: -Observe single service items (pill cups) stored unprotected on the med carts.Unused medication cups shall be kept covered or inverted. 15A NCAC 18A .1318 (c).-Observed residue collecting in the bottom of drawers in one of the two medication carts.Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −2
-Repeat Non-Compliance: Observed the bottom of the vanities in the salon with water damage.-Observed stain recliner cushion in room 125.-Observed water damage under the sink in the activity room.All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
#43 · Food storage units with thermometers, maintain temperatures −0.5
Repeat Non-Compliance: Observed several refrigerators without thermometers (bedrooms and common areas).All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b).
Apr 15, 2015 92 / 100 · 7 violations
Inspector comments: 2. Observed debris and single service items on the floor in the nurse storage. Clean.Keep all flooring clean. 15A NCAC 18A .1309 (a).16. Obseved no backup water supply plan. Guidline form emailed.Observed no backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f). 36. -Observed buildup and old popcorn in the popcorn machine (2nd floor).-Observed the interior of the refrigerator in the HV Living room and in room 113 collecting residue.All kitchenware and food contact surfaces of equipment, exclusive or cooking surfaces of equipment, used in preparation or serving of food or drink, and all food storage utensils, shall be cleaned after each use. 15A NCAC 18A .1320 (c).43. Observed no thermometer in the refrigerator in room 113, and a moldy thermometer in the HV living room refrigerator.All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b).Mr. Elvin was present at the beginning of the inspection. Mr. Matthew Fowler was present for the remainder of the inspection.Report and the Instatution Rule Book emailed to Mr. Fowler and Ms. Tammy Mullins.
#3 · Walls and ceilings cleanable, clean, good repair −1
-Repeat Non-Compliance: Observed water stains on ceiling in upstairs hallway.-Observed the wall over the shower in 132 in need of caulk.Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#4 · Lighting at least 10 foot candles 30 inches above floor −1
Repeat Non-Compliance: Observed the light in the nurse storage closet very dim. Provide more lighting.All areas shall have sufficient illumination. Maintain 10 foot candles of light at 30 inches above the floor in all areas other than food service areas. 15A NCAC 18A .1311 (a).
#8 · Facilities conveniently located, clean and in good repair −1
-Repeat Non-Compliance: Observed soiled (brown on the bottom) shower curtain in room 132.Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).-Observed loose toilet seat in room 113.Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). -Observed room labeled "Storage" with 2 large trash cans containing bags of soiled briefs, bed pads, etc. Room has a very strong odor.Handwashing sinks shall be accessible to all areas where personnel may be exposed to bodily excretions or secretions. 15A NCAC 18A .1312 (d).
#19 · Ice protected, dispensed, equipment clean in good repair −1
Observed ice stored on the counter top in the Dining room (HV side). At certain times no staff was supervising the area. (Pitcher of juice was also on the counter. Ensure it is protected against contamination also).Ice shall be handled, transported, stored, and dispensed in such a manner as to be protected against contamination. 15A NCAC 18A .1314 (b).
#28 · Adequate storage, area clean, items properly stored −1
-Repeat Non-Compliance: Observed briefs and/or bed pads stored on the floor in the restrooms and closets in multiple rooms.All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).-Observed towels stored under the restroom handsink in 210.Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −2
-Repeat Non-Compliance: Observe single service items (pill cups & utensils) stored unprotected on the med carts.Unused medication cups shall be kept covered or inverted. 15A NCAC 18A .1318 (c).-Observed residue collecting in the bottom of drawers in one of the two medication carts.Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
-Observed soiled mattress cover in 105.-Observed stain couch cushion in room 212.-Observed the bottom of the vanities in the salon with water damage.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).
Dec 4, 2014 93.5 / 100 · 6 violations
Inspector comments: General Comment: #4. Observed light not working in storage room at entrance to memory care unit. Replace blown light bulb in fixture or replace light fixture.**All areas shall have sufficient illumination. Maintain 10 foot candles of light at 30 inches above the floor in all areas other than food service areas. 15A NCAC 18A .1311 (a). #5. Observed some dust on front of ventilation in hallway in memory care unit and on front of ventilation(1) ventilation cover in assistant living unit. Thoroughly clean ventilation cover in hallway and residents room.**Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). #24. Observed some ants around night stand area in room 103(assistant living). Contact exterminator to address any ant issues. Observed baby snake on side walk behind facility. Also have exterminator to address any snake issue!**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). #32. Observed some dust on top of television and wall fixture in resident room in memory care. Dust top of fixture and wall fixture in residents room often/regular to prevent the accumulation of dust.**All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a). Mr. Carlos Huertas and Mrs. Mary Posse present at time of inspection.
#2 · Floors clean, carpet clean, dry, odor free −1
Observed floors soiled in laundry room area and several storage closets throughout facility. Observed spots/stains on carpet in several resident room. Thoroughly clean floor in laundry room area and storage closets! Shampoo carpet throughout where needed. Keep all flooring clean. 15A NCAC 18A .1309 (a).
#3 · Walls and ceilings cleanable, clean, good repair −1
Touch-up paint wall throughout in resident room, bathrooms and hallways. Observed damaged wall in laundry room(memory care) and area behind can wash area( 1st floor assistant living) and janitor closet. Patch holes in wall and repaint. Patch hole around plumbing fixture under hand washing sink in resident room or place scution cup around plumbing fixture. Observed water stains on ceiling in hallway and storage closets. Monitor ceiling for any roof leaks or condensation leaks from ventilation duct and repair if needed. Clean top of half walls in memory care unit. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. All walls shall be easily cleanable. 15A NCAC 18A .1310.
#8 · Facilities conveniently located, clean and in good repair −1
Observed damaged handrail in shower, damaged shower wand and soiled shower curtain in room 133. Observed some shower heads and shower curtain with microbial growth present. Thoroughly clean shower head and shower curtains throughout! Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
#15 · Approved water supply, no cross-connections −2
Observed no back flow prevention device on sink basin in salon. Provide a back flow prevention device on sink basin in salon!Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).
#28 · Adequate storage, area clean, items properly stored −0.5
Observed storage on the floor in upstairs storage room and residents briefs stored on the floor in residents closet and bathroom. Store items in storage room on shelving or dunage racks and store residents briefs on shelving in bathroom or closet area.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
Observed single service articles not properly stored on med carts. Pill cups on med cart were stacked to high without any protective covering. Store single service articles(pill cups) in original sleeving or in a ziploc bag on med carts. Observed (1) pill crusher on 1st floor soiled. Thoroughly clean pill crusher often/regular to prevent build up on pill crusher! Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c). Unused medication cups shall be kept covered or inverted. 15A NCAC 18A .1318 (c).
Jun 10, 2014 93 / 100 · 6 violations
Inspector comments: Mr. Carlos Huertas present during inspection.GC #42: Food thermometer in refrigerator in room 225 reading 55F. Make sure residents keep food below 45F in personal refrigerators.**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).GC #34: Documentation from laundry service provider on chemical used to sanitizer common laundry and if a method of testing strength is available. Provide documentation that equipment is operating properly.**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 several chemical spray bottles unlabeled or mislabeled.
#3 · Walls and ceilings cleanable, clean, good repair −1
Observed wall damage in 1st floor laundry. Wall damage in stairwell on 2nd floor landing. Ceiling stains 2nd floor hallway.**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 toilet chairs or toilet below toilet chair needing cleaning in rooms 121, 214. Pink and black mold on shower mat in room 121. Water damage inside cabinet, activities area. Product build-up on chair in salon.**Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).**Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).**Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
#11 · Hand sinks used only for intended purpose −1
Observed dirty silverware and flowers in hand sink, memory care.**Except for the stipulations stated in rule .1312 (d), handwashing sinks shall only be used for handwashing. 15A NCAC 18A .1312 (d).
#15 · Approved water supply, no cross-connections −2
Observed no backflow preventer on sink basin in salon and shower wand in room 121.**Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).
#19 · Ice protected, dispensed, equipment clean in good repair −1
Observed unprotected ice on counter in memory care.**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).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Observed single service spoons stored with bowl up. Single service spoons stored in cup with hair and a test strip in it, one med. cart.**Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c).
Nov 11, 2013 92.5 / 100 · 6 violations
Inspector comments: Mr. Carlos Huertas present during inspection.GC # 15: Observed no backflow preventer at sink in salon.**Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).GC # 24: Observed ants in women's bathroom, hall 1st floor.**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).GC # 16: New maintenance director couldn't locate back-up water supply plan (ED off-site). Plan given does not sufficiently spell out the required details (it's ambiguous).**Observed no backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f).**The backup water supply plan shall provide for two liters of water per day perperson for drinking. The backup water supply plan shall include a plan for either relocating residents or providingan alternative source of water for essential functions such as food preparation, hand washing, bathing, cleaning,dishwashing, laundry and disposal of bodily waste. The amount of water provided for uses other than drinking maybe reduced if the plan includes alternatives for water use for services such as laundry and dishwashing. If anassessment determines that tap water is not to be used for drinking, sources shall be prominently labeled or hoodedto restrict use and potable water shall be provided.
#2 · Floors clean, carpet clean, dry, odor free −1
Observed carpets not being vacuumed in storage closets. Flooring with build up/staining in laundry room.**Keep all flooring clean. 15A NCAC 18A .1309 (a).
#8 · Facilities conveniently located, clean and in good repair −1
Observed sink in memory care (kitchenette) not being cleaned frequently enough. Plumbing leak at wash sink in salon. Bath mat and floor of shower under bath mat with residue build-up, room 122.** Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
#28 · Adequate storage, area clean, items properly stored −0.5
Observed unlabeled comb (with hair in it) in cabinet of hall bathroom, memory care.**Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −2
Repeat Non-Compliance: Observed single service cups and pill cups not protected on assisted living and memory care halls. Med cart drawers in memory care needed cleaning out.**Unused medication cups shall be kept covered (on a clean surface) or inverted. 15A NCAC 18A .1318 (c).**Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −2
Repeat Non-Compliance: Observed lots of trash under cushions of furniture in common areas. Chair in salon needs cleaning of product build-up.**All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
#36 · Approved utensils and equipment, cleaned and sanitized −1
Observed drawers and cabinets in memory care need wiping out, food and debris spills. One drawer off it's track, memory care, kitchenette.**All kitchenware and food contact surfaces of equipment, exclusive or cooking surfaces of equipment, used in preparation or serving of food or drink, and all food storage utensils, shall be cleaned after each use. 15A NCAC 18A .1320 (c).
Source: Mecklenburg County Public Health – Environmental Health public inspection portal (search for “TERRABELLA LITTLE AVENUE” or State ID 2060400085). Inspection type (routine vs. follow-up) is not published in the county's data.