98/ 100
PAVILION HEALTH CENTER AT BRIGHTMORE
10011 PROVIDENCE RD W, Charlotte, NC 28277
Rest/Nursing Homes · NC permit/State ID 2060400135
Latest result98 / 100
Last inspectedMay 28, 2026
Inspections on record20
On record sinceFeb 6, 2014
Score history
Feb 6, 2014Higher is betterMay 28, 2026
Inspections & violations
May 28, 2026 98 / 100 · 2 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 rusting toilet chair in room 213. Replace.
#16 · Hot water between 105°F and 116°F
.1313 (d) Institutions shall provide water heating facilities. Hot and cold running water under pressure shall be provided to carry out all operations. Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities. Observed hot water at 117-121F on 300s hallway. Ensure hot water is between 105-116F.
Oct 1, 2025 96 / 100 · 6 violations
#2 · Walls and ceilings clean, good repair −2
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. Observed scuffed/peeling walls and door frames in various areas throughout facility. Keep in good repair.
#5 · Ventilation equipment clean, good repair
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed ceiling vent in staff bathroom with heavy dust buildup. Keep clean.
#7 · Facilities provided, accessible, clean, good repair
.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 204. Tighten. Observed toilet in rehab men’s bathroom in need of cleaning.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair −1
.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 torn/stained mat next to bed in room 204. Repair/replace mat.
#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 microwave with food debris in rehab kitchen. Observed broken handles on kitchen cabinets throughout facility. Observed microwave with food debris in activity kitchen near front lobby. Observed nourishment room fridge with spills in need of cleaning. Observed food splatter on cabinets in activity kitchen near front lobby. Keep clean. REPEAT
#40 · Handwash lavatory provided and properly equipped
.1320 (c) Any area where food is portioned, served, or handled shall be equipped with a handwashing facility with a hot and cold mixing faucet, soap, and single-use towels or a hand-drying device. Observed broken automatic paper towel dispenser in rehab kitchen. Repair or keep paper towels next to sink at all times.
Mar 14, 2025 96.5 / 100 · 3 violations
#2 · Walls and ceilings clean, good repair −2
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. Observed wall scuffs in hallways and in resident rooms throughout facility. Repair. REPEAT
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair −1
.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 stained couches in common areas and cabinet handles missing or broken in nourishment rooms. REPEAT
#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 with food debris in PT kitchen. Keep clean. REPEAT
Aug 21, 2024 96 / 100 · 8 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 stained ceiling tiles in room 410. Replace tiles. REPEAT.
#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 loose toilet seat in hall bathroom near DON office. Observed rusting toilet chairs in 210 and 105. Observed toilet in need of cleaning in 114. Observed stain on shower curtain in 114. Needs cleaning/repair. Observed light out in shower in room 114. REPEAT.
#16 · Hot water between 105°F and 116°F
.1313 (d) Institutions shall provide water heating facilities. Hot and cold running water under pressure shall be provided to carry out all operations. Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities. Observed hot water at 118 in spa rooms, and 311.
#23 · Solid waste containers properly constructed, covered where required; good repair
.1316 (a) All solid wastes containing food scraps or other putrescible materials shall be kept in leak-proof, non-absorbent containers which shall be kept covered with tight-fitting lids when not in use. Observed dumpster lids missing. Needs new lids.
#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 cups stored with lip of cup unprotected on one medication cart. Needs to be stored covered.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair −1
.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 worn chair in room 311. Observed debris on fall pads in room 114 and 206. Observed one stained pillow and one pillow torn in room 210. Observed cabinet handles missing or broken in nourishment rooms. REPEAT.
#33 · Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled
.1319 (b) Bed linens that are provided by the institution for use by residents shall be free from holes and tears. Observed tear in blanket in room 210 needs replacement.
#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 build up in microwave and refrigerator in nourishment room 1. Observed build up in microwave in PT kitchen. Needs cleaning.
Sep 12, 2023 96 / 100 · 7 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free
1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair. Observed flooring in room 106 need to be clean.
#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 stain ceiling tile in room 303. Check for active leaks if any, repair or replace the ceiling tile.
#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 and toilet chairs need detail cleaning in room 203, 305, 105. Observed rusted toilet chairs need repair or replace in room 209, 210, 305, 316, 401, 106.
#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 two restroom in the gym without the hand washing sign posted. Hand 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 paper towel dispenser is not working causing no paper towel to be available in room 105, spa room back hall way, laundry room. Check and repair/replace batteries of the dispenser. Provide all hand washing supplies at all time at all hand sinks.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair −0.5
REPEAT
.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair. Observed damaged/stain blue hospital pillow in room 218, 116. Need replacement when damaged or stain. Observed damaged wheelchairs seat/arm rest, therapy pillow in the gym need repair or replace.
#34 · Linens provided by the institution properly cleaned and sanitized −1.5
.1319 (c) Linens provided by the institution that are not clean shall be cleaned and sanitized in accordance with this paragraph. When hot water in washing machines is used to sanitize linens provided by the institution, the washing machines shall be operated in accordance with the manufacturer's instructions. When chemicals are used to sanitize linens provided by the institution, linens shall be washed in accordance with the following:
(1) using a solution of at least 50 parts per million chlorine; or
(2) using laundry sanitizer that is registered in accordance with 40 C.F.R. 152 and that is used in accordance with the manufacturer's instructions.
-Observed the facility without laundry maintenance records recording the content of chemical that use to sanitize linens provided by the facility. Obtain records and keep on file at each service by the service provider.
Nov 7, 2022 97 / 100 · 3 violations
Inspector comments: No points deducted: #3- Observed walls needing to be repainted through out including in various rooms. Painters are already scheduled to start painting then entire facility in the next few weeks. Residents are already being moved to different halls in preparation.
#18 · Drinking utensils properly handled −1
Observed water pitcher’s unlabeled in room 204.
Label all disposable water pitchers with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Observed cups unprotected on 200 and 200 hall med carts.
Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed debris under couch cushions in common area near kitchen. Observed brown chair needing to be resurfaced or replaced in room 416.
Mattresses shall be kept clean, dry, and odor free. 15A NCAC 18A .1319 (a).
Nov 19, 2021 96 / 100 · 3 violations
Inspector comments: No points deducted for the following violations:
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed wall damage in wing 200 near storage closet and paint touch up needed adjacent on the adjacent wall. Repair wall damage and paint.
Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed soiled linen in room 210. Clean linen.
#1 · Floors easy to clean, no obstacles, drains where needed −2
Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b). Observed door sweep coming apart from the floor at house keeping door in hall 400 near room 417. Repair door sweep. -REPEAT VIOLATION-
#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 room 210. Repair toilet seat. No point escalation due to significant improvement. -REPEAT VIOLATION-
#28 · Adequate storage, area clean, items properly stored −1
All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). Observed patient care items in boxes stored directly on floor in soiled utility room in hall 100. Properly store patient care items. -REPEAT VIOLATION-
Mar 9, 2021 95.5 / 100 · 5 violations
#1 · Floors easy to clean, no obstacles, drains where needed −1
Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b). Observed flooring torn in server 100/200 halls
#8 · Facilities conveniently located, clean and in good repair −1
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed very rusted toilet chair in room 105.
Handwashing sinks shall be accessible to all areas where personnel may be exposed to bodily excretions or secretions. 15A NCAC 18A .1312 (d). Observed several blocked sinks
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed hoppers not being cleaned regularly.
#19 · Ice protected, dispensed, equipment clean in good repair −1
Ice shall be handled, transported, stored, and dispensed in such a manner as to be protected against contamination. 15A NCAC 18A .1314 (b). Observed lid removed in nourishment room 100/200 hall. Ice exposed. CDI-lid put back on.
#28 · Adequate storage, area clean, items properly stored −0.5
Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a). Observed soiled wiping rags under steamwell in servery near kitchen.
#36 · Approved utensils and equipment, cleaned and sanitized −1
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). Observed cabinets and drawers in nourishment rooms need wiping of spills. Both microwaves rusted with broken handles in nourishment rooms. Refrigerator needed spills cleaned, 300/400 hall.
Observed grilling machine in nourishment room. Believed to be staff member's grilling machine. Remove to employee lounge if belongs to staff and kitchen if belongs to facility.
Oct 29, 2019 95 / 100 · 4 violations
Inspector comments: 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 Safety Data Sheet (SDS) for sanitizers and disinfectant. CDI; nurse administrator provided SDS for all products used.
Tighten toilet seat in Rm 114 all other toilets were tight.
#9 · Toilet rooms free of storage, hand wash signs posted −1
Toilet rooms shall not be used for storage. See rule .1312 (b). Observed storage in bathroom in Rooms 207 & 218
Keep handwashing signs posted in all staff restrooms. 15A NCAC 18A .1312 (b). Post handwashing sign in both male and female toilet in therapy gym.
#14 · Disinfectant accessible, properly used −1
Bathing facilities as required by the licensing agency shall be provided, maintained and kept clean. Shared bathing equipment that has contact with patient's skin shall be cleaned with detergent and an EPA registered hospital disinfectant between patient uses.
A supply of cleaning and disinfectant agents shall be accessible to bathing areas. Observed debris in spa both tubs and observed no EPA registered hospital cleaner and disinfectant in any spa bathing area.
#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 build up residue on sides and back of medication cart in 300 Hall.
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −2
Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean
linen. 15A NCAC 18A .1319 (b). Observed clean linen on floor and on shelf in linen storage rooms in 100 Hall and 300 Hall.
Apr 29, 2019 95 / 100 · 5 violations
Inspector comments: NO POINTS TAKEN
#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 burnt out light build in the bathroom of room 318.
#8 Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed loose tiolet seats in two bathrooms within the facility.
#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 hot water temping at 118F in room 414 and temping at 118F in room 318.
#32. All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a). Observed debris under sofa seats in lounging areas. Observed stain on sofa in room 412. Observed stains on curtain in room 207.
Led by Alexis Welch EHS # 2806
#14 · Disinfectant accessible, properly used −1
A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). Observed no EPA registered hospital cleaner and disinfectant in any spa bathing area within the facility.
#18 · Drinking utensils properly handled −1
Label all disposable water pitchers with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a). Observed several water pitchers without patient's first name and last name through facility. Particularly on halls 300 and 400 within facility.
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Observed unused cups on medication carts throughout facility uncovered.
Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c).
#33 · Linen changed when soiled. Soiled linen handled properly −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 stains on linen in rooms 103, 114, 304, and 412. Observed holes in pillow at rehabilation center.
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. 15A NCAC 18A .1319 (b). Observed a cart of clean linen being stored in mop sink area within the laundry room.
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 laundry maintenance records showing that a minimum of 50 ppm chlorine or washed in 160F for 25 minutes
Nov 20, 2018 94.5 / 100 · 5 violations
Inspector comments: NO POINTS:
#14 A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). Observed no disinfectant present in 2 spa room.
#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 broken drain plug at dumpster.
#28 All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). Observed patient care items that were stored on the floor in storage room. In room 203 observed patient care items not labeled and items not separated between patients.
#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 staff personal items co-mingled in with clean linen in clean linen storage room.
***Inspection co led by Imani Grimes and Kiana Chrisp***
#3 · Walls and ceilings cleanable, clean, good repair −1
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
Observed dinged and marred surfaces of walls and door frames throughout. Observed a soiled wall in Spa #1. REPEAT.
#8 · Facilities conveniently located, clean and in good repair −2
#8 Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed rusty shower chair in room 414 and 103. Observed soiled shower seat in room 318. Observed black staining on bottom of shower curtain in room 203. Observed brown stains on floor around toilet in room 418. Observed scale buildup on shower head in rooms 414 and 103
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed yellow stains on toilet and brown stains on toilet seat in room 418. Observed yellow stains on toilet in room 318. Observed the shower bed in the SPA #1 with hair and debris.
#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −0.5
Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).
In room 318 and 103 observed bed pans not labeled.
All bedpans/urinals/emesis basins shall be cleaned after each use. 15A NCAC 18A .1312 (c).
In room 318 observed soiled unlabeled bed pan.
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).
Observed no facility to clean bedpans inside of room and PIC stated that they cleaned bedpans inside of rooms.
#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 pill crusher with heavy build-up. REPEAT.
Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c).
On med cart observed water pitcher with pink slime around the handle and also black residue on the inside around top portion.
#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 a ripped mattress in room 103. Observed a ripped pillow in room 209. REPEAT.
May 23, 2018 90 / 100 · 8 violations
Inspector comments: NO POINTS:
#14: Skin contact surfaces of all shared bathing equipment shall be cleaned with a detergent solution and then disinfected with an EPA registered hospital disinfectant between patient uses. 15A NCAC 18A .1312 (f). Observed that rehab disinfectant wipes did not have labeleing for use in a hospital or nursing home or have an EPA number and didn't say disinfectant.
#42: 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). Observed food in refrigerator at 50F in room 203. TCS food disposed of
**Provide a written back-up water supply plan.**
#3 · Walls and ceilings cleanable, clean, good repair −1
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed dinged and marred surfaces of walls and door frames throughout.
#8 · Facilities conveniently located, clean and in good repair −1
Toilet, handwashing, and bathing facilities must be conveniently located and readily accessible to residents and staff. 15A NCAC 18A .1312 (a). Observed hopper very soiled and drain flies in abundance. Clean more frequently.
Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b) Observed sinks in clean utility and soiled utility not on a regular cleaning schedule. Very soiled.
#13 · Lavatory and bathing hot water between 100 and 116 F −1
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 hot water throughout facility at 124F.
#21 · Solid waste stored properly, areas clean, facilities for cleaning −2
Observed hole in dumpster. Needs replacing. Keep doors closed. Keep containers/cans drained
#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 med cart drawer with powder at bottom. Pill crusher with heavy build-up.
Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c). Cups stored in a dirty plastic bag. Change bag more frequently.
#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 damaged mattress in room 215. Gum on underside of bedside table, room 105. Dusty blinds throughout. Damaged table top of bedside table.
#33 · Linen changed when soiled. Soiled linen handled properly −2
Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b). Observed carts in laundry for soiled laundry with clean items on the side. Label soiled laundry carts and use only for soiled.
Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed soiled or torn/stained linens, pillow, or heel float in rooms 104, 105.
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. 15A NCAC 18A .1319 (b). Observed cart covers damaged on carts in small closets. Non-linens items stored with clean linens. Carts soiled/stained. Trash accumulation in storage rooms.
Dec 18, 2017 94 / 100 · 6 violations
Inspector comments: Mr Richard present.
No points deducted: Observed blue ice cooler lid broken in nourishment room.
Observed can wash needing to be cleaned, gloves and trash present.
#2 · Floors clean, carpet clean, dry, odor free −1
Observed stains/spills on floor in storage room near 216, 115 and in 311, and in soilen linen closets. Carpets being replaced and under contract.
Keep all flooring clean. 15A NCAC 18A .1309 (a).
#3 · Walls and ceilings cleanable, clean, good repair −1
Observed stains on walls and or wall damage(paint scraped) in rooms 109, 115, 204, 215(including doorframe), and salon. Observed cove base needing to be resealed to wall in housekeeping closet near salon.
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 rust on toilet chair in room 109. Observed hair in sink in Salon. Observed tub with debris in unused spa room.
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).
#28 · Adequate storage, area clean, items properly stored −1
Observed patient care items stored on floor in storage closet on 300 hall. Repeat.
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 pill crushers needing to be cleaned.
Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).
#36 · Approved utensils and equipment, cleaned and sanitized −1
Observed water pitchers not being taken to kitchen for proper washing, rinsing, and sanitizing. Must be done daily.
All multi-service utensils shall be washed, rinsed and sanitized between each user using a method listed in 15A NCAC 18A .2619.
Jun 26, 2017 93.5 / 100 · 7 violations
Inspector comments: Mr. Richard was present during inspection today.
2)Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed cleaning needed on floor, behind bed in 204.
32) All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).Observed couches and chairs in common area in need of more frequent 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 walls in need of touch up paint throughout facility. Observed stained ceiling tile in 307. REPEAT VIOLATION
#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −0.5
Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c). Observed only one bed pan with a name, and no date. Observed all other bedpans with no labeling.
#14 · Disinfectant accessible, properly used −1
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). Through discussion, no housekeeper could properly describe how long to let the disinfectant sit on a surface for disinfecting. Ensure that surfaces are being disinfected.
#28 · Adequate storage, area clean, items properly stored −0.5
All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). Observed patient care/contact items stored on floor in 300 hall storage.
#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 damaged linen in 216. Observed stained linens in 114. Observed linen with crumbs in 307. REPEAT VIOLATION
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 employee move soiled laundry out of bin and place in larger bin with no cover. Discontinue this practice and be sure to either bag linen or cover when transporting to laundry area.
Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b). Observed one soiled linen tub in soiled linen closet with no label. Observed canvas transport cart for soiled laundry with no label.
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. 15A NCAC 18A .1319 (b). Observed toileting supplies stored along with clean linen. Observed personal items including handbags and food trays stored in clean linen closets.
NOTE: Observed clean linen carts covered with mesh material that does not protect against contamination when stored on the hallway.
#43 · Food storage units with thermometers, maintain temperatures −0.5
All refrigerators shall maintain a temperature of 45°F or below. 15A NCAC 18A .1323 (b). Observed refrigerators in 218 and 204 to be above 45F. Thermometers were reading above 45F as well. CDI: Refrigerators were turned down to become colder.
Dec 12, 2016 97 / 100 · 3 violations
Inspector comments: No points deducted: Shower wand in room 303 observed with hair on it. Room 401 (unclean) observed stains on pillowcases and comforter.
#2 · Floors clean, carpet clean, dry, odor free −1
Observed stain on 100 hall floor near room 102.
Keep all flooring clean. 15A NCAC 18A .1309 (a).
#3 · Walls and ceilings cleanable, clean, good repair −1
Observed wall damage/ scuff marks in hallways and in various rooms.
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Observed pill crushers needing to be cleaned on med carts.
Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c).
Jun 29, 2016 96.5 / 100 · 4 violations
Inspector comments: (NO POINTS DEDUCTED)
12. Observed paper towel dispenser jammed in clean linen and soiled utility 100/200 hall. Dispenser was repaired. Ensure paper towels feeding at all times.
Observed trash cans not provided in 400 clean linen/soiled utility closets at hand sinks. Provide trash cans at all hand sinks or means to discard paper towels.
21. Observed debris build up located around outside dumpster.
Provide documentation that laundry in being disinfected at a minimum of 50 ppm chlorine next visit.
Ms. Lee Cole and Mr. Richard Applegate were present during inspection.
#8 · Facilities conveniently located, clean and in good repair −1
Observed soiled shower bed in spa #1.
Observed 1 urinal soiled in 310
Observed hand sink located in clean linen 100/200 hall blocked by wheel chairs. Relocate wheel chairs for accessible hand washing.
**Toilet, hand washing, and bathing facilities must be conveniently located and readily accessible to residents and staff. 15A NCAC 18A .1312 (a).
**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 briefs stored on floor in rehab gym restroom, storage closet at end of 300 hall.
Observed bag of pillows stored on floor in clean linen 200 hall.
**Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a).
#30 · Medication carts clean, sharps containers affixed, food and utensils handled properly −1
Observed pill crushers soiled on med carts located 100 hall, 400 hall.
Observed drinking cups in need of covering on med carts to protect from contamination located 100, 400 hall.
**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).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed stains on recliner in room 310, 416.
Observed stained linen/comforter in room 101, 112,
**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 3, 2015 94.5 / 100 · 6 violations
Inspector comments: ***GC #1: Observed trash on floor in several storage rooms. Provide trash cans in rooms or take trash to trash can. **Keep floors clean.Provide documentation that laundry in being disinfected at a minimum of 50 ppm chlorine.
#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 a few soiled toilet chairs throughout the facility. Soiled shower bed in spa room. Soiled toilet in spa. Hopper with ring in bowl-put onto regularly cleaning schedule.Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −1
REPEAT VIOLATION: 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). Observed that the bedpans are being cleaned in the residents rooms and the resident rooms do not have spray arms on their toilets. Advised that they should be using the soiled utility room with the hopper.Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c). Observed that the reusable bedpans are not being labeled properly with the name and date.
#14 · Disinfectant accessible, properly used −1
REPEAT VIOLATION: Skin contact surfaces of all shared bathing equipment shall be cleaned with a detergent solution and then disinfected with an EPA registered hospital disinfectant between patient uses. 15A NCAC 18A .1312 (f). Observed that the housekeeping is unaware of 'contact time' and what that means. Explained what contact time is during the inspection and advised that contact time should be explained to all staff members.
#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 residue built up inside of the ice machine in the nourishment room.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 that an employee was bringing a cart of ice around to the rooms in a chest like cooler full of ice and the employee left the ice chest unattended when going into patient rooms. Advised that it should be more protected and to use an automatic dispenser.
#28 · Adequate storage, area clean, items properly stored −0.5
Observed boxes stored on floor in storage rooms. Keep storage a minimum of 8 inches above the floor.All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. 15A NCAC 18A .1319 (b). Observed linen carts not covered in rooms containing non-linens. Soiled pillow case thrown in clean linen closet.
Mar 19, 2015 94.5 / 100 · 4 violations
Inspector comments: 2. Observed several of the soiled utility room floors collecting debris and residue.Keep all flooring clean. 15A NCAC 18A .1309 (a). 28. Observed chemicals stored over paper towels and toilet paper in multiple storage and/or housekeeping closets. Rearrange (chemicals under the single service items) to prevent possible contamination.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. Observed residue (a red liquid) collecting in the bottom of a drawer in a medicine cart.Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).32. -Observed a soiled couch cushion in the common area by the 100 & 200 halls.-Observed soiled and torn pillows in the rehab gym.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 residue collecting in the freezer and refrigerator in the nourishment room.-Observed residue collecting in the nourishment cabinets and spice packet containers.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).Ms. Myrna & Mr. Tom present during the inspection.Inspection emailed to mgibson@liberty-ltc.com*Awaiting on the laundry hot water information. Facility does not use bleach. Fax the information from the service company to Nykesse Roberts as soon as it is received.
#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −1
Repeat Non-compliance: Observed unlabeled bed pans.Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).
#12 · Lavatories have mixing faucet or tempered water, soap hand towel and hand drying device −1.5
Observed no soap at the handsinks in a soiled utility room near the 100/200 hall and in both of the spas.Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d).
#14 · Disinfectant accessible, properly used −1
-Per an CNA, the bathing equipment is sprayed with disinfectant, wiped off, then rinsed with water. Ensure the manufacturer's instructions are followed (10 minute contact time etc).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).-No one knew how to clean the tubs in the spas. After finding the instruction booklet, the correct chemical was located as well as the cleaning instructions. Per Tom, the instructions will be copied and posted in the spas.The manufacturer's instructions shall be followed for cleaning equipment with pumps. See rule .1312 (f).
#18 · Drinking utensils properly handled −2
Repeat Non-Compliance: Observed unlabeled disposable water pitchers in rooms in a few rooms.Label all disposable water pitchers with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a).
Oct 6, 2014 96.5 / 100 · 4 violations
Inspector comments: 2. Observed restroom floor in 212 collecting urine with a strong urine smell.Keep all flooring clean. 15A NCAC 18A .1309 (a).19. Observed coolers of ice stored unattended in an unlocked and/or opened nourishment room.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).36. Per multiple nurses, the water pitchers on the med carts are washed in the nourishment rooms. They all have been informed to send them to the kitchen to be washed, rinsed, and sanitized. They have also been informed to receive to drinking water from the kitchen (not the handsink in the nourishment rooms).All multi-service utensils shall be washed, rinsed and sanitized between each user using a method listed in 15A NCAC 18A .2619.Ms. Myrna & Mr. John present during the inspection.Inspection emailed to: mgibson@liberty-ltc.com
#8 · Facilities conveniently located, clean and in good repair −1
-Repeat Non-Compliance: Observed no hand sanitizer in the salon. 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). -Observed soiled toilet seats and/or 3 in 1 toilet seat in rooms 408, 413, 212, soiled shower chair in room 309, shower stretcher pad ripped exposing the inside cushion with hair and brown matter under the pad.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 Non-compliance: Observed unlabeled bed pans.Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).
#18 · Drinking utensils properly handled −1
Repeat Non-Compliance: Observed unlabeled disposable water pitchers in several rooms.Label all disposable water pitchers with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a).
#33 · Linen changed when soiled. Soiled linen handled properly −1
Observed soiled pillow cases and/or sheets and comforters in 408, 413, and 212.Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).
Feb 6, 2014 98 / 100 · 3 violations
Inspector comments: Observed no hand sink or hand sanitizer in salon.**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).
Observed unlabeled soiled linen bins. **Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b).
Observed single service spoons not inverted on med cart.**Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c).
#43 · Food storage units with thermometers, maintain temperatures −0.5
Observed no thermometers in refrigerators throughout.
**All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b).
#10 · Bedpans, urinals, bedside commodes and emises basins properly cleaned and disinfected −0.5
Observed unlabeled bed pan.
**Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c).
#18 · Drinking utensils properly handled −1
Observed unlabeled water pitchers.
**Label all disposable water pitchers with the resident’s/patient’s first name and last name. 15A NCAC 18A .1314 (a).
Source: Mecklenburg County Public Health – Environmental Health public inspection portal (search for “PAVILION HEALTH CENTER AT BRIGHTMORE” or State ID 2060400135). Inspection type (routine vs. follow-up) is not published in the county's data.