98/ 100
PEAK RESOURCES-CHARLOTTE
3223 CENTRAL AV, Charlotte, NC 28205
Rest/Nursing Homes · NC permit/State ID 2060400128
Latest result98 / 100
Last inspectedMay 13, 2026
Inspections on record25
On record sinceNov 21, 2013
Score history
Nov 21, 2013Higher is betterMay 13, 2026
Inspections & violations
May 13, 2026 98 / 100 · 6 violations
Inspector comments: *NOTE: Report signed for Executive Administrator, Amanda Pack:
Apack@peakresourcesinc.com
#2 · Walls and ceilings clean, good repair −1
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. Observed minor touch up paint needed to walling throughout facility. Repeat violation, slight improvement from previous report.
#4 · Lighting at least 10 foot candles, 30 inches above floor −0.5
.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 1 light out in shared spa room located on 400 hallway.
#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 1 reused urinal not labeled in room 807. -General comment.
#17 · Back-up water supply plan available and complete
.1313 (e) The institution shall have a written plan to obtain a backup water supply in the event that the institution's primary water supply is interrupted for more than four consecutive hours. The written plan shall identify a backup water supply or alternate source of water that provides two liters of potable water per day per resident and institution employee for drinking and potable water for food preparation, hand washing, bathing, cleaning, dishwashing, laundry, and disposal of bodily waste. This may include a plan for relocating residents to a facility with a water supply that satisfies Paragraph (a) of this Rule. If an institution's primary water supply or backup water supply becomes unsafe for human consumption, then the water sources within the institution, such as sink faucets, shall be labeled or hooded to prevent their use, and the administrator shall provide potable water for use by the institution's residents and employees.
Facility could not locate back up water supply plan during time of inspection. EHS emailed facility template for creating required procedure plan. -General comment.
#26 · Premises properly maintained
.1316 (d) An institution's exterior premises, including parking lots, lawns, and walkways, and interior premises within the institution's building or buildings, shall be kept free of garbage, solid waste, yard trash, and pest harborages. Observed minor trash/litter surrounding dumpster area. -General comment.
#43 · Food brought into the institution by employees or visitors of patients or residents properly stored, labeled and dated −0.5
.1321 (b) Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply as described in rule .1321 (a). Such food shall be labeled with the name of the resident or employee that the food belongs to and the date the food was brought into the institution. Labeling as required by this Rule shall not be required for food items stored in employee-designated or individual residents' refrigerators or rooms. Observed several outside food items not labeled according to notated rule in both nourishment area refrigerators located within facility.
Dec 11, 2025 99 / 100 · 3 violations
#2 · Walls and ceilings clean, good repair −1
Observed ceiling peeling and baseboard in need of repair in the janitor closet on the 800 hall. Needs to be repaired. Improvement from last inspection. Repairs have been ongoing.
**.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair.
#7 · Facilities provided, accessible, clean, good repair
Observed slow drain in room 104. Fixed during the inspection.
**.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.
#20 · Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair
Observed ice cooler left unlocked and unattended on 100 hall. Ice cooler was empty at the time. Reminded staff that the cooler should be kept lock because someone could still come and possibly contaminate the cooler.
**.1314 (c) Ice shall be protected against physical, chemical, and biological contamination and shall be kept clean.
Jun 24, 2025 99 / 100 · 3 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free
Observed linoleum floor in need of repair underneath the ice machine in the nourishment room on the 600 hall.
**1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair.
#2 · Walls and ceilings clean, good repair −1
Observed dining room wall in need of touch up paint on 100 hall in nourishment room, room 203 and nourishment room on 600 hall.
**.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair.
#33 · Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled
Observed stained linen on bed in room 203. Room is currently not being used. Linen removed during the inspection.
**.1319 (b) A resident's bed linens shall be changed when no longer clean.
Sep 11, 2024 98.5 / 100 · 5 violations
#7 · Facilities provided, accessible, clean, good repair
Observed chemical sink in laundry room in need of cleaning.
**.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair.
#8 · Toilet rooms free of storage, handwash signs posted −0.5
Observed several hand washing sinks missing hand wash signs.
**.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.
#12 · Bathing facilities properly equipped, equipment cleaned and disinfected
Observed shower bed torn in spa. Shower bed was removed during the inspection.
**.1312 (f) Bathing equipment that has contact with a resident's skin and is used by more than one resident shall be kept clean and shall be disinfected between resident uses. Equipment located within a bathing facility that uses a pump to move water shall be kept clean in accordance with the manufacturer's instructions.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair −1
Observed divider curtain stained in room 605. Removed during the inspection. Observed cable outlet cover in need of 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.
#33 · Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled
Observed torn linen on bed in room 605. Removed during the inspection.
**.1319 (b) Bed linens that are provided by the institution for use by residents shall be free from holes and tears.
May 29, 2024 97.5 / 100 · 7 violations
#2 · Walls and ceilings clean, good repair −1
Observed wall damage behind the bed in room 201. Observed wall staining in room 607. Observed wall damage in room 605. Observed wall staining in janitor closet on 800 hall. Observed wall staining/damage in room 809.
**.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair.
#5 · Ventilation equipment clean, good repair
Observed dust build up on vent filter in room 809.
**.1311 (b) Ventilation equipment shall be kept clean and in good repair.
#7 · Facilities provided, accessible, clean, good repair −1
Observed toilet in need of cleaning in spa on 700 hall. Observed rusted toilet chair in room 605 and 809. Observed towel holder in need of repair in room 405 (not currently in use).
**.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair.
#12 · Bathing facilities properly equipped, equipment cleaned and disinfected
Observed shower bed in need of cleaning in 500 hall spa and shower chair in spa on 700 hall. Cleaned during the inspection.
**.1312 (f) Bathing equipment that has contact with a resident's skin and is used by more than one resident shall be kept clean and shall be disinfected between resident uses. Equipment located within a bathing facility that uses a pump to move water shall be kept clean in accordance with the manufacturer's instructions.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair −0.5
Observed staining on mattress and curtain in room 809. Observed dresser peeling in room 402, 607 and 909. Observed debris under couch cushions in living room. Observed stained curtain in spa on 400 hall.
**.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair.
#33 · Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled
Observed sheet torn in room 201. Sheet was replaced.
**.1319 (b) Bed linens that are provided by the institution for use by residents shall be free from holes and tears.
#37 · Wheelchairs, walkers, lifts, and other mobility equipment properly cleaned and sanitized
Observed odor in the closet used to store wheelchairs.
**.1319 (f) Wheelchairs, walkers, lifts, and other mobility equipment shall be kept clean and sanitized between uses by different residents.
Nov 15, 2023 98.5 / 100 · 6 violations
#2 · Walls and ceilings clean, good repair
Observed wall damage behind the bed in room 607. Needs to be repaired.
**.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair.
#5 · Ventilation equipment clean, good repair
Observed dust build up on vent filter in room 307.
**.1311 (b) Ventilation equipment shall be kept clean and in good repair.
#20 · Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair
Observed build up in the ice chute in the nourishment room on the 600 hall.
**.1314 (c) Ice shall be protected against physical, chemical, and biological contamination and shall be kept clean.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair
Observed blue pad on physical therapy equipment torn. Equipment was removed during the inspection.
**.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair.
#33 · Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled −0.5
Observed blanket torn in room 307. Needs to be replaced.
**.1319 (b) Bed linens that are provided by the institution for use by residents shall be free from holes and tears.
#38 · Food service equipment and utensils clean, good repair −1
Observed laminate on cabinet missing in the nourishment room on the 600 hall. Observed interior of microwave in need of cleaning in nourishment room on 600 hall.
**.1320 (a) All food service equipment and utensils shall be kept clean and in good repair.
Apr 20, 2023 97.5 / 100 · 3 violations
#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 shower chair stained in the spa on the 400 hall. Observed shower bed and chair torn in the spa on the 600 hall. Observed toilet stained in room 707.
#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 footboard peeling in room 201. Observed bottom of mattress torn in room 105.
#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 laminate on cabinet missing in the nourishment room on the 600 hall.
Nov 9, 2022 95.5 / 100 · 4 violations
Inspector comments: No points were deducted for the following:
2. Observed debris on the floor in storage room on 400. Needs to be cleaned.
**Keep all flooring clean. 15A NCAC 18A .1309 (a).
8. Observed shower bed torn in spa on 400 hall. Needs to be replaced.
**Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
10. Observed labels missing on disposable urinals in rooms 107, 505 and 809.
**Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).
44. Observed boxes of water stored on the floor in the storage room on 400.
**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).
#3 · Walls and ceilings cleanable, clean, good repair −2
Observed touch up paint needed throughout facility. Observed ceiling in need of touch up paint in the janitor closet on 800.
**Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#9 · Toilet rooms free of storage, hand wash signs posted −0.5
Observed chairs stored in spas on 400 and 500.
**Toilet rooms shall not be used for storage. See rule .1312 (b).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Observed med cups stored unprotected on med cart on 800 hall.
**Unused medication cups shall be kept covered or inverted. 15A NCAC 18A .1318 (c).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed fusion torn on equipment in physical therapy. Observed bed frame peeling in rooms 403 and 605. Observed arm of chair (stored in spa) peeling.
**All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in in stitutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
Feb 8, 2022 94 / 100 · 4 violations
Inspector comments: 2. Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed floor stained in soiled utility room next to 400 hall. Observed baseboard had fallen off and a staining possibly from a spill on the floor in janitor closet on hall 400. Observed damage to the floor at the entrance doors on the 800 hall. Observed tile cracked next to toilet in bathroom of occupational therapy room. Needs cleaning or repair.
5. Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). Observed build up of dust in vent in spa bathroom on 600 hall.
9. Toilet rooms shall not be used for storage. See rule .1312 (b). Observed wheelchair stored in spa room in 700 hall. Observed chair and wheelchair being stored in spa in 600 hall. CDI - Items were removed from spa.
21. All solid wastes containing food scraps or other decomposable materials shall, prior to disposal, be kept in leak-proof, non-absorbent containers, which shall be kept covered with tight fitting lids when filled or stored, or not in continual use. 15A NCAC 18A .1316 (a). Observed lids on dumpsters broken. Needs repair.
28. All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). Observed boxes of diapers on floor in bathroom of room 711. Needs to be 8 inches above the floor.
30. Unused medication cups shall be kept covered or inverted. 15A NCAC 18A .1318 (c). Observed cups stacked high on medication carts and uncovered on 900 hall and in 100 hall. Cups should be kept covered.
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 stained sheets on bed in room 203. Needs cleaning.
#3 · Walls and ceilings cleanable, clean, good repair −2
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed damage to the wall in soiled utility room next to 400 hall. Observed damage to wall behind headboard of bed in room 408. Observed section of wall loose in laundry room. Observed wall damage at floor board which manager stated is from a water leak and has a work order in for repair. Needs repair. REPEAT.
#8 · Facilities conveniently located, clean and in good repair −2
Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b) Observed sink linoleum damaged in soiled utility room. Observed caulking wearing away at handsink in activity kitchen on 100 hall. Observed caulking and linoleum damaged at sink in nourishment room in 600 hall. Observed linoleum peeling under sink and caulking wearing away in bathroom of spa on 600 hall.
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed toilet chair torn in storage room next to 400 hall. Observed toilet chair rusting in room 203. Observed toilet chairs cushion torn in spa in 700 hall. REPEAT.
#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 handle on cabinet missing in activity room kitchen and handle loose on activity room cabinet. Observed cabinets and drawers with debris in nourishment room on 600. Observed headboard and footboard peeling on beds in rooms 408 and 203. Observed recliner torn and arm of wheelchair beginning to tear in room 906. Needs repair. REPEAT.
#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 of residue and debris in refrigerator in nourishment room in 600 hall. Needs cleaning
Jul 22, 2021 96 / 100 · 2 violations
Inspector comments: No points were deducted for the following:
32. Observed dresser paint peeling and foot board on bed peeling in room 106. NOTE: Improvement from previous inspection.
**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 cabinet in need of cleaning in dining area on 100 hall. Observed laminant peeling on the cabinet in nourishment room on 600 hall. Observed interior of microwave in need of cleaning in the pantry on the 100 hall. Observed build up on ice chutes.
**Non-food contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. See rule .1320 (c).
#3 · Walls and ceilings cleanable, clean, good repair −2
Observed wall damage in rooms 610 and 703, and employee restroom on service hall. Needs to be repaired.
**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 torn shower bed in the spa on 600 hall. Observed stained shower chair in spa on 700 hall.
**Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
Observed toilet loose in the employee restroom on service hall.
**Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
Observed sinks in need of caulking in pantry on 100 hall, nourishment room on 600 hall, and employee restroom on service hall.
**Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
May 20, 2021 97 / 100 · 3 violations
Inspector comments: NO POINTS FOR THE FOLLOWING VIOLATION:
#21. All solid wastes containing food scraps or other decomposable materials shall, prior to disposal, be kept in leak-proof, non-absorbent containers, which shall be kept covered with tight fitting lids when filled or stored, or not in continual use. 15A NCAC 18A .1316 (a). Observed dumpster top lid opened during time of inspection.
NOTE: EHS Anna Ortiz was present during time of inspection along with Head of Housekeeping Ms. Dot and Head of Maintenance Paul.
ghenderson@peakresourcesinc.com
b6w@hscgops.com
#3 · Walls and ceilings cleanable, clean, good repair −1
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed touch up paint needed to walls in residents rooms.
#8 · Facilities conveniently located, clean and in good repair −1
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed loose toilet seat in rooms 301 and 502.
#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 build up under couch cushions in living rooms throughout. Observed mattress peeling in room 409.
Dec 2, 2020 97 / 100 · 3 violations
Inspector comments: NO POINTS FOR THE FOLLOWING VIOLATION:
#34. Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. 15A NCAC 18A .1319 (b). Observed boxes of diapers stored on clean linen cart on 500 hallway.
*NOTE: Ms. Dot and Paul was present during time of inspection. Inspection report was emailed to the following:
ghenderson@peakresourcesinc.com
b6w@hcsgops.com
#3 · Walls and ceilings cleanable, clean, good repair −1
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed wall behind sink in nourishment room on 600 hallway in need of repair. Observed minor scuff markings to walls throughout facility in residents rooms.
#19 · Ice protected, dispensed, equipment clean in good repair −1
Ice machines, buckets, other containers, and scoops shall be cleaned on a regular schedule such that they are kept free of scum, rust, mold or other contamination. 15A NCAC 18A .1314 (b). Observed pink slim build up in nourishment room located on 600 hallway.
#33 · Linen changed when soiled. Soiled linen handled properly −1
Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed staining on fitted sheet located in room 701.
Jan 29, 2020 95 / 100 · 5 violations
Inspector comments: GENERAL COMMENTS NO POINTS FOR THE FOLLOWING VIOLATIONS:
#3. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed minor scuff markings throughout facility to walls.
#13. Maintain the hot water at all resident accessible handwashing sinks and bathing facilities within the temperature range of 100°F to 116°F. 15A NCAC 18A .1312 (e). Observed handsink reach 88F in room 609 and 97F in room 611.
#14. 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 hospital disinfectant accessible in shared spa room located on 400 hallway.
#34. All common linen including sheets, pillow cases, absorbent pads, towels, and wash cloths provided by the facility must be sanitized between users with an EPA registered laundry sanitizer or by other methods described in 15A NCAC 18A .1319 (b). Observed no documentation within indicating that common linen is being disinfected. EHS informed head of housekeeping to have their service provider, Ecolab, to start leaving the facility with documentation of how much disinfectant is being pumped into washer when common linens are being washed.
*NOTE: Paul and Ms. Dot was present during time of inspection. Inspection report was emailed to the following: ghenderson@peakresourcesinc.com
#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 two lights out over two separate showers in shared spa room located on 700 hallway.
#8 · Facilities conveniently located, clean and in good repair −1
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed loose toilets seats in the following areas: room 205, shared spa room located on 400 hallway and, shared spa room located on 600 hallway.
Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed slits in bathing mats in shared spa rooms.
Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b). Observed handsink in nourishment kitchen located on long term side of facility needing to be recaulked to wall.
#19 · Ice protected, dispensed, equipment clean in good repair −1
Ice machines, buckets, other containers, and scoops shall be cleaned on a regular schedule such that they are kept free of scum, rust, mold or other contamination. 15A NCAC 18A .1314 (b). Observed pink and black build up located inside of ice machine located in nourishment kitchen on long term care side of facility.
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a). Observed food debris under pull out couch cushions in "living room" areas throughout facility.
#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 food debris in bed in rooms 609 and 707. Observed soiled diaper stored on top of bed linen in room 611.
Aug 1, 2019 94.5 / 100 · 6 violations
Inspector comments: 3- Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed dining rooms near front entrance and in park place with wall damage and patient rooms with scuffs.
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 two spas with lights out above the shower.
6- Moisture shall be controlled such that there is no evidence of microbial growth on interior surfaces and objects. 15A NCAC 18A .1311 (d). Observed air vents in hallways with build-up of dust and debris.
17- Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a). Observed drinking fountains in need of cleaning, visible microbial growth.
#8 · Facilities conveniently located, clean and in good repair −1
Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).Observed all spas in each hall in need of cleaning tis includes toliet chairs, shpower chairs, lay down shower facilities, toliet seats. Observed room 904, 805, 403, 208 with visible spoilage on toilet chair.
#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 all soiled utility rooms being used for storage. Not a correct area for storage due to cotamination.
#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 ice drinking cart with ice chest on it where ice chest was able to be opened by the public or a resident. Cart sits in kitchen area normally when not being used to pass out drinking water. CDI-PIC moved cart to a locked room and was informed cart needs to remain unaccesible to the public.
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c). Observed medication cart down hall 300, 800, 900 visibly soiled and a few loose pills in hall 300 cart.
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a). Observed stained chairs in lounge areas, dining rooms, and patient rooms. Observed damaged tables, soiled food trays in room 403, 904.
#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). Oberved stained sheets inrooms 605, 901, stianed pillow cases in room 403, 904.
Apr 25, 2019 96 / 100 · 3 violations
Inspector comments: No points were deducted for the following:
10. Observed disposable urinal not dated in room 803. Needs to be properly labeled.
**Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).
Observed disposable urinal in need of cleaning in room 803.
**All bedpans/urinals/emesis basins shall be cleaned after each use. 15A NCAC 18A .1312 (c).
12. Observed no paper towels at the handwashing sink in Clean Utility room on short term hall.
**Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d).
17. Observed water fountains with build up during inspection. Needs to be cleaned.
**Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a).
21. Observed dumpster doors open. Ensure that doors are closed after trash is placed in to reduce to occurrence of pests.
**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).
NOTE: Inspection led by Alexis Welch under the supervision of Jamil Blackmon.
#8 · Facilities conveniently located, clean and in good repair −1
Observed toilet chair soiled in room 901. Needs to be cleaned.
**Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
Observed shower bed surface cracked and soiled in the spa on Northlake Village hallway.
**Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
#28 · Adequate storage, area clean, items properly stored −1
Observed outdoor storage area in need of arranging.
**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 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −2
Observed clean linen stored on cart with disposables and gloves on 900 and 100 hall. Repeat.
**Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. 15A NCAC 18A .1319 (b).
Nov 29, 2018 96.5 / 100 · 3 violations
Inspector comments: No points were deducted for the following:
12. Observed no paper towels at the handwashing sink in the Private Dining room. Paper towels were provided during inspection.
**Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d).
14. Observed no disinfectant solution in the spa on the 400 Hallway. Disinfectant was provided.
**A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).
42. Observed nutritional supplement dated for 11/21 on med cart on 400 hallway. Product label states product should be discarded after 4 days of opening. Product was discarded during inspection.
**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).
#5 · Ambient air temperature 65 to 85 F, equipment clean −1
Observed HVAC filters with build up in rooms 306 and 509. Ensure filters are being cleaned at a high enough frequency to avoid accumulation. REPEAT.
**Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).
#28 · Adequate storage, area clean, items properly stored −0.5
Observed storage closet on the 400 Hallway with many items stored on the floor. Closet needs to be cleaned and organized.
**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 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −2
Observed items such as disposable undergarments, gloves and paper gowns stored with clean linen on the clean linen cart on the
300 and 800 hallway. REPEAT.
**Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent
contamination of clean linen. 15A NCAC 18A .1319 (b).
Jan 3, 2018 96 / 100 · 3 violations
Inspector comments: No Points Deducted for the Following:
5. Observed ventilation filters in need of changing in rooms 509 and 208.
**Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).
13. Observed water temperature at 97F in room 710. Needs to be adjusted to ensure compliance.
**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).
32. Observed worn mattress beginning to peel, exposing mesh covering. Needs to be replaced to ensure moisture is not allowed to seep into mattress cushioning.
**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. See rule .1319 (a).
#8 · Facilities conveniently located, clean and in good repair −2
Observed soiled shower chair in Spa on The Plaza hallway. Observed stained shower bed in Spa on the 700 hallway. Observed soiled hopper in Soiled Utility room on The Plaza hallway. Items needs to be thoroughly cleaned. Observed slow drain in room 710. Needs to be repaired. Observed loose toilet seat in room 208. Needs to be tightened.
**Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
**Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
**Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
#33 · Linen changed when soiled. Soiled linen handled properly −1
Observed soiled linen on bed in room 611. Needs to be changed. Observed soiled towel on shower bed in spa. Observed soiled rag hanging in spa. Soiled items to be placed in appropriate locations. Observed soiled towel in the bathroom of room 611.
**Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).
**Soiled linen shall be placed in a covered container or bag at the point of use and stored and handled so as to contain and minimize aerosolization of and exposure to any waste products. 15A NCAC 18A .1319 (b).
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
Observed items such as disposable undergarments, gloves and paper gowns stored with clean linen on the clean linen cart on the 400 hallway.
**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).
Jul 21, 2017 96.5 / 100 · 4 violations
Inspector comments: Elisa Matheney was present during the inspection.
15A NCAC 18A .1306 PUBLIC DISPLAY OF GRADE CARD (a) Whenever an inspection of an institution is made, the Environmental Health Specialist shall remove the existing
grade card, issue a new grade card, and post the new grade card where it may be readily observed by the public upon entering the facility. The administrator shall be responsible for keeping the grade card posted at the location designated by the Environmental Health Specialist at all times. If the administrator objects to the location designated by the Environmental Health Specialist, then the administrator may suggest an alternative location which meets the criteria of this Rule.
NO PINTS WERE ISSUED FOR THE FOLLOWING:
#2 - Observed the treatment closet floor with debris. **Keep all floors clean.
#12 - Observed no paper towels were supplied at the hand washing sink in the med prep room. **Each hand washing areas must be supplied with soap and paper towels.
#18 - Observed disposable drinking cups throughout the facility were not labeled with the patient's name and date. ****Label all disposable water utensils with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a).
#26 - Observed wasp nests, birds nests, and dirt dauber nests on exterior porches. **Remove all nests from the premises.
#28 - Observed clean items were stored with-in 1 inch of hand washing sink. **Keep all clean supplies out side of spa-zone of the hand washing sinks to prevent contamination. Recommend 12 inches on both sides.
#8 · Facilities conveniently located, clean and in good repair −1
Observed a shower chair with damaged / worn mesh backing and was not clean. **Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
Observed sinks were very slow to drain in rooms 505 and in the spa room. **Keep all hand washing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
Observed a soiled elevated toilet chair was stored in the clean utility room with other clean chairs, and the hopper was not clean in the soiled utility room. **
**Observed a significant improvement. **Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −0.5
(REPEAT) Observed bed pans were not labeled with the resident's name and date in rooms 505 and 409.
**Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).
#19 · Ice protected, dispensed, equipment clean in good repair −1
Observed the ice machine shoot with pink and black residue in the nourishment room.
**Ice machines, buckets, other containers, and scoops shall be cleaned on a regular schedule such that they are kept free of scum, rust, mold or other contamination. 15A NCAC 18A .1314 (b).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed soiled transport cart was stored in a storage closet, the chair upholstery was not clean in room 505, the divider curtain was not clean in room 604, and plastic lined pillows were worn/torn in room 804
Jun 7, 2017 88.5 / 100 · 9 violations
Inspector comments: Chris Brides was present during the inspection.
CONTINUED FROM PAGE 2: #8 - Observed the sink was blocked by soiled linen bins in the soiled utility room (short term care), sinks blocked in spa rooms with excess storage of lifts, wheelchairs, reliners etc., no hand sink or hand higene procedure for beautician in the salon. Ensure that the beautician has hand sanitizer to clean hands before washing her hands in the hallway restroom. **Handwashing sinks shall be accessible to all areas where personnel may be exposed to bodily excretions or secretions. 15A NCAC 18A .1312 (d). **Facilities in operation prior to March 1, 2003 that do not have handwashing lavatories in all areas required shall have an approved hand hygiene program established. 15A NCAC 18A .1312 (d).
NO POINTS WERE DEDUCTED FOR THE FOLLOWING:
4. Observed the lights not working in the restrooms in rooms 108, 502. **Ensure there is adequate lighting in all areas.
10. Observed a bedpan was not labled in room 712. **Ensure that all bedpans are labeled with the resident's name and date issued.
15. Observed the condensate line (top) of the ice machine is directly plumbed in the nourishment room; the bottom condensate line needs an air-gap. **Properly install pump, so that waste water in the top condensate line pumps to drain.
28. Observed boxes of medical supplies were stored on the floor in a long term wing storage closet.**All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
36. Observed a microwave that runs while the door is open, and had damaged interior surface. Keep all food service equipment in good repair.
#3 · Walls and ceilings cleanable, clean, good repair −1
Observed the floors were not clean in 502, 609, the ceiling was not cleaning room 502 restroom.
**Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
NOTE: Finish all repaired walls where they are smooth and painted.
#8 · Facilities conveniently located, clean and in good repair −2
Observed a bedside commode was not cleaned after use in room 406, the toilet was not clean in room 807, **Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
Observed shower chairs, shower stretchers with pink residue and mildew in the community spa rooms throughout the facility, the shower grout with mildew in the community shower rooms throughout the facility, a broken shower head in a shower in the spa room . **Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
#14 · Disinfectant accessible, properly used −2
(REPEAT)Observed no disinfectant solution available in to community spa/shower rooms, and no disinfectant used by the housekeepers in the showers on 3 different hallways. **A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).
#16 · Quantitiy and hot water sufficient, backup water supply plan −1
(REPEAT) Observed the back-up water supply plan was not complete. It was missing the amount of water supplied for each resident per day, how toilets would be flushed, etc. A guidance document including a checklist for creating a complete document was provided by email. **Observed an incomplete backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f).
#19 · Ice protected, dispensed, equipment clean in good repair −1
(REPEAT) Observed several unattended ice chest carts on the hallways. Ice carts should always be attended when on the hallway, or locked up.
**Ice shall be handled, transported, stored, and dispensed in such a manner as to be protected against contamination. 15A NCAC 18A .1314 (b).
**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
(REPEAT) Observed sticky residue in some med cart drawers, some single service drinking cups were stored unprotected on med cart.
**Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).
**Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c).
NOTE- Ensure that all water pitchers are thoroughly washed, rinsed, and sanitized daily.
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed living room couches with food debris beneath the cushions, several blue mattresses with worn/damaged surfaces, several reclining chairs with damaged surfaces, and a separation curtain was soiled in room 502.
**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 the soiled linen bins in the salon were not labeled. **Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b).
Observed sheets with holes in room 609,
#40 · Food brought by employees or visitors handled properly −0.5
Observed several food items from outside sources were not labeled in long term care nourishment room refrigerator.
**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).
**Food brought from home by employees or visitors of patients or residents shall be kept only as long as it is clean, and free from spoilage. 15A NCAC 18A .1321 (b).
Sep 13, 2016 95.5 / 100 · 4 violations
Inspector comments: (NO POINTS DEDUCTED)
3. Obsered slight wall damaged behind bed in room 907. Touch up wall.
10. Observed urinal soiled with resiude in room 803. Urinals shall be disinfected after each use.
14. Observed bottle of disinfectant empty located in 600, 700 hall.
16. Observed back up water supply plan provided from supplier with calculation of water per resident. Calculation was short (2 liters per person per day). Contact supplier and provided 2 liters per resident per day.
18. Observed multiple staff at med carts describe cleaning of drinking pitcher at 600 hall nourishment room. Pitchers shall be taken to kitchen to be washed, rinsed, and sanitized between uses.
19. Observed ice chest unattended to 800 hall way. Keep ice protected and or supervised at all times to prevent contamination.
Mr. Paul and Mr. Drew was present during inspection.
#8 · Facilities conveniently located, clean and in good repair −1
Observed blue spa mat with slight build up between at holes in 800/700 spa. Ensure full mat is being properly cleaned.
Observed back of shower chairs starting to breakdown in 600/700 spa.
Observed 1 underside of shower chair collecting residue in 700/600 spa.
**Improvement seen from previous inspection.
**Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
#28 · Adequate storage, area clean, items properly stored −0.5
Observed boxed items stored on floor in following areas: Med prep right wing of facility, 400 storage closet, outside storage area.
Observed bag of clean linen stored on floor in clean linen 600 hall.
**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).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Observed pill debris, debris, and sticky residue present on 900,
Observed drinking cups on med cart overstocked with mouth contact portion not protected 400 and 500 hall.
**Unused medication cups shall be kept covered or inverted. 15A NCAC 18A .1318 (c).
**Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).
#33 · Linen changed when soiled. Soiled linen handled properly −2
Repeat Non Compliance: Observed debris in linen, stains on linen, comforter and or pillow case in room 803, 403, 604.
Repeat Non Compliance: Observed lids not closed at soiled linen container in soiled utility closet (500/400 hall)
Observed carts in soiled laundry room not labeled "soiled linen" just labeled linen (500 hundred hall)
Observed linen stored in shower tub 700/600 spa.
Observed rip in linen room 403 and 902.
**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).
**Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b).
Jun 24, 2016 96 / 100 · 2 violations
Inspector comments: (NO POINTS DEDUCTED)
1. Observed flooring in slight disrepair in 600 nourishment. Keep floor in good repair.
16. Back up water supply plan provided. Ensure 2 liters of drinking water are provided per person per day.
30. Observed 1 med cart collecting slight debris 900 hall. Keep med cart drawer free of residue build up. Observed 1/2 of drinking cups same cart 900 hall not fully protected. Keep all mouth contact portions of drinking cup free of potential contamination by either placing bag over cups and or keeping supply below holster.
32. Observed rip in transport chair located in 700/600 spa with rips and tears in arm rest. Arm rest in need of repair.
Mr. McDaniel and Mr. Drew Richard were present during inspection.
#8 · Facilities conveniently located, clean and in good repair −2
Observed residue on under side of toilet chair in room 907.
Observed debris build up in holes of blue shower mat in 800 spa.
Observed dark residue collecting around grout in several showers throughout 600-900 halls.
Observed dried urine residue on floor in room 907.
**Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
**Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
#33 · Linen changed when soiled. Soiled linen handled properly −2
Repeat Non Compliance: Observed stains on linen, comforter and or pillow cases in room 709, 805, and room 204.
Observed lids not closed at soiled line container in soiled utility closet (500 hall) and clean linen 600 hall.
**Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b)
Dec 4, 2015 93 / 100 · 4 violations
Inspector comments: l#5) Observed dusty air vent in common area living room. Keep all ventilation clean and in good repair.#19) Observed ice dispensing station left unattended. Ice shall be protected from potential contamination.#16) Observed water in room 305 at 90F. Maintain hot water at 100-116F.#28) Observed single box of patient care items stored on floor in storage room. Box was relocated. #30) Observed med cart drawer 300 with slight debris build up. Drawers in need of routine cleaning.Inspection completed by Devonna Hendrix reviewed and signed off by Alex Torres REHS
#8 · Facilities conveniently located, clean and in good repair −2
Repeat Non-compliance. Observed shower chairs with pink residue on underside in Spa in 600 Hall. Observed soiled toilet in room 907 and 600 spa room. Observed red residue on floor in 600 Hall Spa room. Observed urine stains on toilet in rooms 907 and 203. Observed soiled bathing mats in 600 Hall Spa Room. **Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).**Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −1
Observed unlabeled bed pans in rooms 104, 203, 812, 907, 403. Observed soiled bed pan in room 104**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 no EPA registered disinfectant in 600 Hall Spa room.**A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).
#33 · Linen changed when soiled. Soiled linen handled properly −2
Repeat Non-Compliance. Observed soiled linen, ripped comforter and stained pillowcases on beds in rooms 104, 203, 907, 305, 403. Observed no linen on the bed in room 907.**Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).
Jan 15, 2015 95 / 100 · 5 violations
Inspector comments: Shonda Wingate (administrator) and Victor Rios (Maintenance) were present during the inspection.#4 - Observed one light was not functioning in Myers Park/Northlake Spa restroom. Keep all lighting in good repair.#12 - Observed no soap supplied at the hand washibg sink in the laundry room. Soap was supplied during the inspection. **Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). #21 - Observed the ground around the dumpster with litter and garbage debris. **Solid waste containers, rooms, or designated areas shall be kept clean. 15A NCAC 18A .1316 (c).#28 - Observed a box of gauze was stored on the floor in a storage room. **All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
#7 · Indoor smoking limited to dedicated smoking rooms −1
Observed patient smoking on the livingroom porch and cigarette smoke coming back into the living room.**Smoking rooms shall be ventilated to prevent environmental tobacco smoke from moving into other portions of the building. 15A NCAC 18A .1311 (e).
#8 · Facilities conveniently located, clean and in good repair −1
Repeat Non-Compliance: Observed shower chairs in the spas with pink residue beneath the seats; observed a soiled shower chair in the occupational therapy restroom.**Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).Observed a portable toilet basin was soiled in room 507. **Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).Observed the backsplash at the hand washing sink was water damaged and needs caulk in The Plaza Nourishment room.**Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
#14 · Disinfectant accessible, properly used −1
Observed no disifectant available for the occupational therapy bathroom shower.**A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).
#19 · Ice protected, dispensed, equipment clean in good repair −1
Observed the ice shoot on the ice machine with pink residue in The Plaza Nourishment room.**Ice machines, buckets, other containers, and scoops shall be cleaned on a regular schedule such that they are kept free of scum, rust, mold or other contamination. 15A NCAC 18A .1314 (b).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed several drawers with accumulated food debris 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).
Jul 10, 2014 91.5 / 100 · 7 violations
Inspector comments: GC #9: Observed storage in bathroom of room 603.**Toilet rooms shall not be used for storage. See rule .1312 (b). GC #34: Observed no data for amount of chlorine residual going into each washine machine.**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).Note: Observed chemicals in spray bottles that were mislabeled. Properly label all chemicals. Buckets of cleaners with rags in them, cleaning cart, and used rags on another cleaning cart. Dispose of chemicals and used rags at end of shift.
#8 · Facilities conveniently located, clean and in good repair −2
Observed shower beds with torn mattresses, hall 500 hall and 600 hall. Many toilet chairs with residue on undersides throughout facility. Loose toilet seat in 900 hall spa. Clean hoppers even if not used-getting ring around basin. Bottom sides of toilet chairs with residue in clean utility room, 800 hall.**Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).**Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)**Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).
#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −0.5
Observed unlabeled bed pans in rooms 405 and 307.**Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).
#14 · Disinfectant accessible, properly used −1
Observed no disinfectant available in spa, 500 hall. No cleaning instruction for spa's posted in any bathroom.**A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f).**The manufacturer's instructions shall be followed for cleaning equipment with pumps. See rule .1312 (f).
#19 · Ice protected, dispensed, equipment clean in good repair −1
Observed ice scoop holder's with slime build-up. Send through dish machine daily.**Ice machines, buckets, other containers, and scoops shall be cleaned on a regular schedule such that they are kept free of scum, rust, mold or other contamination. 15A NCAC 18A .1314 (b).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Observed several pill crushers with pill/powder build-up. Spill in med cart drawer, 500 hall.**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 frayed fall mats in room 405. Brown chairs in rooms with discolored cushions, arms, and backs rooms 909 and .**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 many pillows with tears throughout facility. Soiled linens on beds in rooms 503, 602, 405, 307, and 204.**Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).
Nov 21, 2013 94 / 100 · 5 violations
Inspector comments: 3. Observed HVAC vents collecting dust in 'South Park Place' spa, and 'Ballentyne Heights' hall restroom.Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.14. -Observed CNA in 'North Lake Village' spa clean the shower chairs by spraying the disinfectant on it, letting it sit for 4 minutes, then spraying it down with water. -Per the CNA on the 'South Park Place' hall, and the housekeeper on the 'Wendover Way' hall, the shower chairs are cleaned by allowing the disinfectant to sit for 5 minutes or immediately spraying it down.*Per the chemical's instructions, the contact time is a minimum of 10 minutes.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).28. -Observed outside storage in need of organization. Items are being stored where the floor is inaccessible to clean when necessary.Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a).-Observed a box of briefs and urinals on the floor in the 'University Crossing' storage & oxygen room.All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).32. Observed a soiled chair cushion in room 304.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).*Ensure employees in the salon are washing their hands. Inspection completed by Nykesse Roberts (500-900 halls) and Eli Freese (100-400 halls).Victor & Keetha present during the inspection.
#8 · Facilities conveniently located, clean and in good repair −2
-Repeat Non-Compliance: Observed toilet chairs, shower chairs, and bathing stretchers soiled throughout spas and resident restrooms.-Repeat Non-Compliance: Observed torn bathing stretcher pad in the spa in 'North Lake Village' hall.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 geri chairs and lifts stored in the spa on the 'Wendover Way' hall.-Repeat Non-Compliance: Observed a geri chair stored in the restroom in room 502.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: CNA explained that bed pans are being cleaned in the patient's showers on the 'University Crossing' hall.Where bedpans are cleaned in patient/resident rooms, bedpan cleaning facilities shall consist of a water closet with bedpan lugs or spray arms. 15A NCAC 18A .1312 (c). Where facilities for cleaning bedpans are not provided in patient rooms, bedpans shall be taken to a soiled utility room and be cleaned and disinfected using an EPA registered hospital disinfectant after each use. 15A NCAC 18A .1312 (c).
#19 · Ice protected, dispensed, equipment clean in good repair −2
-Repeat Non-Compliance: Observed cooler of ice that was stored accessible to patients in the hallway of 'Eastway Terrace'.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 pink build up in all of the blue ice coolers.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).
#33 · Linen changed when soiled. Soiled linen handled properly −1
-Observed linen soiled and collecting debris in rooms 804, 702, & 204.Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).
Source: Mecklenburg County Public Health – Environmental Health public inspection portal (search for “PEAK RESOURCES-CHARLOTTE” or State ID 2060400128). Inspection type (routine vs. follow-up) is not published in the county's data.