97/ 100
NOVANT HEALTH PRESBYTERIAN MEDICAL CENTER
200 HAWTHORNE LN, Charlotte, NC 28204
Hospitals · NC permit/State ID 2060410009
Latest result97 / 100
Last inspectedOct 27, 2026
Inspections on record26
On record sinceNov 14, 2013
Score history
Nov 14, 2013Higher is betterOct 27, 2026
Inspections & violations
Oct 27, 2026 97 / 100 · 7 violations
#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 wall cover coming apart from the wall in the soiled room on side A in the OR.
#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 blood/stains on hand sink in hall restroom in Adult ED. Observed soiled/stained toilet bowl in 7 floor-seclusion rooms, soiled bathroom floor in room 708. Need cleaning and keep clean. Observed slow draining hand sinks in staff restroom 6D, need repair. Observed soiled hand sink around basin and faucet throughout behavioral health restrooms, some hand sinks need caulking and keep good repair.
#10 · Handwashing facilities properly located and equipped
.1312 (d) Handwashing facilities shall be located in an institution in accordance with 10A NCAC 13B .5411, 10A NCAC 13D .3201, 10A NCAC 13F .0305, .1304, and 10A NCAC 13K .1109, .1204, as applicable. Institutions that do not have a handwashing facility located in all areas required by this Paragraph shall not be required to install handwashing facilities if the institution has an approved hand hygiene program.
Observed no paper towels at the dispenser in laundry room 7th floor behavioral health. No soap in the dispenser at nourishment hallway area sink on 6th floor behavioral health. Provide soap/paper towels at all hand sinks at anytime.
#11 · EPA registered disinfectants used according to manufacturers' instructions; approved testing methods and devices used
.1312 (e) EPA registered disinfectants shall be used in accordance with the manufacturer's instructions. When EPA registered disinfectants are mixed and prepared by institution employees, a measuring device, chemical testing device, or the methods and devices prescribed by the chemical manufacturer shall be used to prepare the concentration of chemicals in accordance with the disinfectant's label and the manufacturer's instructions. Observed 1 cart on BH 7 floor did not have disinfectant.
#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 torn mattress and sticker residue in room 6 Adult ED. Observed tape residue on mattress in room 14 in Children's ED. Observed mattress peeling in room 7827 on 7F.
#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 debris build-up on bottom of rear in freezer on unit 3SW. Clean. Observed debris on ice chute on Adult ED nourishment.
Observed soiled refrigerator need cleaning inside 7E refrigerator, cleaning the outside refrigerator and drink machine in 6D. Keep clean.
#43 · Food brought into the institution by employees or visitors of patients or residents properly stored, labeled and dated
.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 patient food stored in refrigerator labeled with name and no date in unit 3SW nourishment
Jun 16, 2026 95 / 100 · 8 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −1
1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair. Observed damaged/peeled floor tiles near soiled room in Labor and Delivery. Observed black residue on floor tiles in shower in room 767 on 7C.
#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 wall scuffed / damaged in patient room #3104 in need of touch-up painting / repair.
#7 · Facilities provided, accessible, clean, good repair −1
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair.
- Observed soiled toilets with ring around the bowl, soiled sinks all around basin, drain, faucet need cleaning in Radiology, Radiology Holding, CT scan department, Flora department, Emergency Department. Observed slow drain need repair at public restroom ED, Flora department, Radiology Holding, ED area A-B. Observed sink need new caulking and repair in ED public restroom, ED nourishment sink in D area.
#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 no hand washing sign in staff restroom in Endoscopy.
#10 · Handwashing facilities properly located and equipped
.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices.- Observed no soap available in soiled utility room ED- D area and no paper towels in soiled utility room in Endoscopy. Ensure to provide all hand washing supplies at all hand sinks at all time.
#16 · Hot water between 105°F and 116°F −3
.1313 (d) Institutions shall provide water heating facilities. Hot and cold running water under pressure shall be provided to carry out all operations. Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities. Observed hot water at 83F in neuro ICU. Observed automatic sink in room 6329 and soiled utility in intermediate ICU not operating. Observed hot water measured at 123F in CT scan 1, the entire unit of Endoscopy at 125F, and Flora restroom at 90F. REPEAT.
#20 · Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair
.1314 (c) Ice shall be protected against physical, chemical, and biological contamination and shall be kept clean. Observed build up in ice chute of ice machine in NICU and in Mother/Baby nourishment.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair
.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair. Observed residue on shower curtain in 767 on 7C. Observed chair cushion ripped in room 802 on Mother/ Baby. Observed clean supply room in (3C) having soiled shelving in need of general cleaning. Observed toilet seat loose in BH 704.
Apr 29, 2025 95 / 100 · 8 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free
1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair. Observed cleaning needed on floors in soiled utility rooms on 7th and 8th floors.
#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 wall damage in SPD. Observed damaged walls and build up on walls in soiled utility in ICU. Observed wall edging loose at entrance to Equipment storage in ICU. Observed stained ceiling tile in room just inside the door on unit 5D. Repeat. No escalation in points.
#7 · Facilities provided, accessible, clean, good repair −1
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed hand sink draining slow (end of hall in Endo near nuclear medicine hallway). Clean around hand sink faucets and toilets in Endo, ED, Radiology. Observed leaking tub faucet and cracked shower handle backing in room on 5D. Observed tub room with stained shower tiles in Neuro ICU. Repeat. No escalation in points.
#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 not operating in PICU 7.
#16 · Hot water between 105°F and 116°F −3
.1313 (d) Institutions shall provide water heating facilities. Hot and cold running water under pressure shall be provided to carry out all operations. Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities. Observed hot water 92-102F in ED guest restroom, ED B station, ED A station. 75-81F in Radiology ultrasound, CT scan, and 118F at Endo sink at end of hallway. 75-78F in room 735 on 7E. Observed hot water reach 99F in PACU and 120F in PICU 7. Observed 6F having 120F-121F at hand sinks throughout. Observed water at 118 in room at 5D. Observed Water at 119 in 5813. Repeat.
#21 · Approved sewage disposal
.1315 (a) All sewage originating from the institution shall be disposed of using a publicly operated sewage treatment plant or an individual sewage disposal system that meets the requirements of Section .1900 of this Subchapter. Observed mop sink in soiled utility in 5A clogged and not draining.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair
.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair. Observed tear on seat cushion in room 769. Work order submitted during the inspection. Observed damaged couch cushion and laminate under couch in 5813. Observed laminate on counter peeling in soiled utility in 5F.
#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 fridge, cabinets and microwave in need of cleaning in nourishment 2 on 5F. Observed microwave and fridge in need of cleaning in nourishment 1 of 5F. Observed cabinets in nourishment room in need of cleaning in CCU and 5C.
Oct 23, 2024 97.5 / 100 · 6 violations
#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 walls needing touch up paint in OR soiled room. Observed scuffed door frames in various areas on 5th, 6th, ICU areas.
#5 · Ventilation equipment clean, good repair
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed vent needing to be reattached in room 766.
#7 · Facilities provided, accessible, clean, good repair −1
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed stained shower grout in 793, 786, and drains needing to be cleaned in 6D, 7D, 7E. Repeat.
#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. Place hand washing sign in staff restroom on 7E.
#16 · Hot water between 105°F and 116°F −1.5
.1313 (d) Institutions shall provide water heating facilities. Hot and cold running water under pressure shall be provided to carry out all operations. Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities. Observed hot water 74F in care station B, 97F room T1267, 86F in CT 1, 97-100F on unit 4300, 79F in room D490. Observed hot water 123F in nourishment on 7F, 97-102F in 6D and 7D. Water 120F in picu 5. Water 85F in 6A. Repeat.
#43 · Food brought into the institution by employees or visitors of patients or residents properly stored, labeled and dated
.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 outside food in nourishment not labeled according to rule.
Apr 24, 2024 98.5 / 100 · 10 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 floors in need of cleaning in the following areas: 6D D697, 7FO common area, Room 7IM 727 floor tile with mold.
#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 damaged walls in 7D 799, wall and ceiling in SNU room 495. Wall damage and soiled, bathroom by CT.
#5 · Ventilation equipment clean, good repair
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed vents in need of cleaning and damaged in 6D D697
#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 slow drain at handwashing sink in the restroom between bays #1 and #2 in ACU. Observed slow drain at handwashing sink in patient restroom in PACU. Hopper with residue ring, Endo soiled utility. Build up around sink fixture, ED #12.
#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 bedpans with no labeling in 7F 7802
#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 below temperature in some 7th floor areas below 100 F, 3C with hot water at 98 F. (Repeat, but observed improvement throughout facility).
#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 common group area furniture on the 7th floor in need of cleaning. Found debris in chair crevices. Treatment room table in need of cleaning and damaged pad in 7D exam room. Observed beds with rust under mattress in room 7F 7801 and 7802. Observed torn couch in room 5811. Observed cracked chair in 6107. Observed torn pillow in Cardiac ICU room 5 and room 6321. Frayed mattress ED #12. Soiled mattress on bottom side, ED hallway clean bed. Tear in scanner bed, CT scan. Torn pillow, CT scan. Tape residue on mattress, ultrasound exam 2. Room 849 chair in labor and delivery damaged. (Repeat)
#33 · Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled −0.5
.1319 (b) Linens that are not clean shall be placed in a covered container or bag devoted to this purpose at the point of use and stored in the covered container or bag until sanitized in accordance with Paragraph (c) of this Rule to contain and minimize aerosolization of and exposure to any waste products. Such covered containers or bags shall be kept clean between uses and labeled to indicate the contents. Observed exposed soiled linen in the following areas: 7F Soiled Utility room, 7IM Laundry room and room 7047. Many soiled linen carts not labeled in ED and Radiology.
.1319 (b) Bed linens that are provided by the institution for use by residents shall be free from holes and tears. Observed damaged bed linen in 6D D697. Torn sheet, isolation room ED.
#36 · Laundry area and equipment kept clean
.1319 (e) Laundry areas and equipment shall be kept clean. Observed interior of some 7th floor clothes washing machines with debris.
#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 food storage cabinets and refrigerators in need of cleaning and/or repair in the following areas. 6D nourishment, 7D nourishment. Observed build up in ICU nourishment 1 refrigerator. Observed build up in microwave in ICU nourishment room 2. Observed build up in refrigerator and microwaves in both nourishment rooms on 5F. Single Service cup dispenser without lid, ED. (Repeat)
Nov 1, 2023 98.5 / 100 · 12 violations
#2 · Walls and ceilings clean, good repair
Observed stained ceiling tile in room 5329. Observed stained ceiling tile in 3004 soiled utility. Observed wall and ceiling chipping in Radiology bathroom and Ed Care.
.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
.1311 (b) Ventilation equipment shall be kept clean and in good repair. Observed broken air filter in A/C unit in 322.
#7 · Facilities provided, accessible, clean, good repair
Observed black residue around shower floor in room 737, 718. Detail cleaning needed. Observed cracked paper towel dispenser (ED Care Bthrm A). Low pressure ED #15.
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair.
#8 · Toilet rooms free of storage, handwash signs posted
Observed no hand washing sign in restrooms where staff have access to. Hand washing signs need to be posted.
#10 · Handwashing facilities properly located and equipped
Missing soap dispenser in ED side A soiled utility.
.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices.
#16 · Hot water between 105°F and 116°F −1.5
Observed hot water ranging from 93-98F on floors ICU, 5A, 5C, 5F, and NICU (nourishment and rooms). Observed hot water at 91F in ACU before reaching 101F. Observed hot water at 100/101 F in 6829. Observed water in 3317 at 95F. Observed water in 3110 at 91/102F. Observed hot water at 89F in 3121. Observed hot water measured between 68F - 102F throughout the floor on 7E & 7D unit. Observed hot water 85F throughout Rad and ED.
.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.
#18 · Drinking fountains clean, good repair
.1314 (a) Drinking fountains shall be kept clean and in good repair. Observed 1 water fountain out of order on 7th floor maternity unit.
#20 · Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair
Observed black residue around ice chute of ice machine in nourishment area of 5A.
.1314 (c) Ice shall be protected against physical, chemical, and biological contamination and shall be kept clean.
#28 · No pest presence; effective pest control measures
Observed drain flies in restroom 737, and room 710
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair
Observed torn pillow in room 11 on ICU. Observed damaged shelf in cabinet in nourishment area in CCU. Observed cabinets in T3009 with debris build up. Observed cleaning needed under family bed in 35 Hospice. Observed cabinet hinge broken in 35 hospice. Observed damaged wheelchair with duck tapes on to hold it together. Observed cuts and tears on guest sofa in room 7807. Need repair or replace.
#33 · Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled
Observed soiled linen not labeled or bag was backwards, or label was faded in several areas (ED or radiology).
.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
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed detailed cleaning needed to microwaves in nourishment rooms on 8th floor on maternity unit and in 4D nourishment area.
Feb 28, 2023 98.5 / 100 · 13 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. Continue to clean floor throughout in common areas, storage rooms, etc. Replace broken base tile cove molding. Clean floor under shelving in clean supply 7F. Clean floor behind washer in 7D
#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. Continue to wipe/clean walls throughout where needed; if needed. Touch up paint door framing and corner edges of walls throughout where needed. Observed walls and doors scuffed throughout in areas, Observed doors chipped throughout in areas (7D, 7E and 7F). Clean scuff marks from walls and doors. Replace or refurbish chipped doors. Clean stains on wall in soiled room(OR-B).
#3 · Ceiling attachments cleanable, clean, good repair
.1310 (b) Light fixtures, fans, conduits, and heating, ventilation, and air conditioning vents shall be kept clean and in good repair. Clean ceiling vents in R730 and R719.
#4 · Lighting at least 10 foot candles, 30 inches above floor
.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 light fixture not operating in fixture above shower in patient bathroom; replace light bulb or repair light fixture.
#7 · Facilities provided, accessible, clean, good repair −1
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Repair broken shower wand holder in (1) bathroom/shower. Observed (2) hand washing sinks not operating at time of inspections. Batteries replaced at time of inspection and hand washing sinks were operating. Observed microbial growth in grout in shower in rooms 707 and 719. Thoroughly clean grout in shower and recommend resealing.Thoroughly clean and disinfect showers daily. Observed old soap and band aid in ledge within shower. Observed soiled shower curtain in room 793 and 730. Thoroughly clean hand washing sink in 7E; observed build up around backside of faucet handles.
#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 no handwashing signs posted employee restrooms throughout. Handwashing signs provided at 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 soap not available at hand washing sink in nourishment area in 7D and at two room in area. (Behavior health)
#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 under required range in the following areas at handwashing sinks: 5C nourishment room, 6C soiled utility room and room 6106. Entire floor of Endoscopy hot water 138F (work order already placed before walk-through). Observed water temperature 100F-104F in ACU and PEDS. Observed water temperature at hand washing sink in nourishment area of 7E 59F. Observed water temperature 75F at bathroom before locked ward. No points deducted. Maintenance was in the process of addressing hot water issue at time of inspection in areas of concerns.
#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 (1) damaged mattress in clean supply room. Discard and replace damaged mattress. Observed (1) bench in lobby area near elevator with damaged leg. Repair or replace damaged bench. Wipe/dust top of high fixtures; light dusting needed. Clean base of computer on wheels(cows).Observed damaged wheel chair near triage room on L &D. Observed damaged chair in 772. Observed debris in base of drawer in a clean vacant room 7806. Observed seating of wheel chair damaged. Recommend replacing damaged seating on wheel chair.
#33 · Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled
.1319 (b) A resident's bed linens shall be changed when no longer clean.
.1319 (b) Bed linens that are provided by the institution for use by residents shall be free from holes and tears. Replace torn pillows in 707, 715, 735. Observed blood on blanket in room 735.
#36 · Laundry area and equipment kept clean
Observed interior of clothes washer machine rusted in 7D. Refurbish or replace lid.
#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 soiled refrigeration unit in 7E. Observed cabinets, and base of drawers with spillage in 7F nourishment.
#44 · Time/Temperature Control for Safety (TCS) foods maintained as required
.1323 (a) All TCS food shall be maintained at temperatures required by Part 3-501.19 of the Food Code incorporated by reference at 15A NCAC 18A .2650 as amended by 15A NCAC 18A .2653 during storage, preparation, transportation, display, and service of the TCS food. Observed milk in nourishment refrigeration unit in 6F unit reading 44F-46F. Temperature in refrigeration unit lowered and milk spaced and placed in back of unit.
Sep 6, 2022 98 / 100 · 2 violations
Inspector comments: #1. Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b). Floors shall be free of obstacles to cleaning. 15A NCAC 18A .1309 (a). Continue to clean floors throughout where needed; bio/soiled utiltiy, storage room etc. Clean floor in dirty tray return room. Repair broken/damaged broken rubber cove molding in bio hazard/soiled utility room.
#3. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Continue to clean walls throughout. Continue to touch-up paint/repaint throughout in rooms, storage rooms, hallways and door framing.
#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 light fixture in shower area not working. Maintenance called and addressed light in shower.
#9. Toilet rooms shall not be used for storage. See rule .1312 (b). Observed transferred cart stored in bathroom/shower. Transferred cart removed from bathroom at time of inspection.
#10. All bedside commodes shall be cleaned after each use. 15A NCAC 18A .1312 (c). Thoroughly clean underside of bedside commodes.
#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). Thoroughly clean area under cushions in rooms. Wipe/dust high fixtures throughout in rooms. Replace torn/damaged cushions on chairs in waiting area or replace chairs. Refurbish physical therapy steps which varnish is wearing from hand railings.
#36. Non-food contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. See rule .1320 (c). Defrost and clean ice from freezer section of refrigeration unit.
#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). Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Thoroughly clean flooring in shower in 5F. Observed several handwashing sinks not operating throughout in several bio/soiled utility rooms. Repair hand washing sinks throughout where needed.
#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). Replace missing ice dispenser/water dispenser guard on ice machine/water dispenser missing protective spouts throughout where needed.
Mar 23, 2022 98 / 100 · 2 violations
Inspector comments: #1.Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b). Floors shall be free of obstacles to cleaning. 15A NCAC 18A .1309 (a). #1. Observed stain on floor in L&D clean storage room. Observed loose edge of floor in hallway area near hospice entrance. Replace missing base molding and secure flooring. Observed flooring dirty under shelves in storage rooms 7D. Laundry vent not attached to dryer, room linty 7D. Floor dirty, personal belongings storage 7E needs cleaning and organizing. Floor with splatters, seclusion room 7E. Missing baseboard under ice machine, 7E. Clean and repair.
#5.Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). 5. Observed rusted ceiling vent D686
#8.Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed shower curtains soiled, 7D, 7E. Hand sink not working, seclusion room 7E. Sink fixtures need better cleaning 7E.
#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). Hot water taking too long hall (6D),bathroom med room (6D) 76F after couple minutes. Med room 117F, 7D.
#36.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 food cabinets dirty in day room, 7D; clean.
#3 · Walls and ceilings cleanable, clean, good repair −1
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. #3. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed minor touch up paint needed to wall joints, baseboards, and walls. CT Scan Room 1: Observed loose border on wall. Reattached securely to wall to prevent further damage. Observed stained ceiling tile near door in L&D clean storage. Wall damage beside recliner in room 869. Observed wall damage in need of repair on 3rd floor ICU. Repair wall beside couch in patient room #6 in Neuro ICU. Patch hole in wall behind door in nourishment room on 6F; highly recommend installing a door stopper behind door. . Paint/seal raw board at hall handwash sink, 6D. Moisture damaged wall, hallway 6D. Paint damage room 785. Wall moisture damaged in corridor between 7D-7E . Paint damaged near phone, 7E.
#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). #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 laminate peelings on counter in soiled utility room located on unit 5C. Observed laminate peelings on counter in soiled utility room located on unit 5C. Observed missing metal from arm rest on recliner in room 871. Repair damaged cabinet in nourishment room on 6th CCU. Replace damage overbed table in room 6328. Replace missing and damaged laminate on base of cabinet in physical therapy room in 6F. Refurbish, reseal, restain furniture/fixture which varnish is worn and wearing off (chair in hospice, physical therapy railing). CT Waiting room: Observed peeling chair cushion. PIC stated that they will replace the chair. Radiology Hall: Observed small tear on patient gurney mattress. PIC stated that they will patch hole on gurney mattress. Observed mattress torn in crib in room 225. Observed torn pillows in D686, D693, 785, 708.
Aug 18, 2021 98 / 100 · 2 violations
Inspector comments: No points were deducted for the following:
2. Observed floors with build-up or debris behind washer/dryers all behavioral health units.
Keep all flooring clean. 15A NCAC 18A .1309 (a).
4. Burnt out lights in EVS closet, 6D.
**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).
28. Observed gloves, pillows, and debris on the floor in soiled utility closets on units 4C and 6F. Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a).
34. Observed clean linen not covered and bag of sheets on floor, clean holding on 6D.
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).
#3 · Walls and ceilings cleanable, clean, good repair −1
Observed hand sanitizer dispenser needing to be resealed to wall in soiled utility room in mother baby.
Observed main door entrance into (6A) scuffed from patient beds hitting surface; Observed equipment room in (6A) having wall scuffs in need of touch-up painting. Observed soiled wall inside bathroom of patient room #5328 in need of cleaning. Observed chipped laminate on wall near nurses station inside (5C) ICU.
Wall damage and window leaks down wall, room 605 on 6D.
**Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#8 · Facilities conveniently located, clean and in good repair −1
Black residue in corners in shower in 876 and black residue around strips in tub in 772. Black scrub marks on outside of tub in 772. Observed hot water side not working in seclusion room, 7D. No water at hand sink in seclusion room, 7E. Hand sink with build-up, 7E laundry room and seclusion room.
**Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
Oct 21, 2020 98 / 100 · 2 violations
Inspector comments: #1. Repair floor in OR sterile core A.
#2. Clean floor in ICU room 11.
#3. Touch-up paint throughout where needed. Observed water stained ceiling in waiting room in ICU/CCU waiting area. Observed build up on wall in soiled storage closet room in 7047. Observed scuffing’s on wall and chippings wall joints throughout unit 7D. Secure metal flashing around elevator on 6th floor.
8. Observed build up around faucet/ aerator screen on hand sink in Ultrasound room 6.
#17 · Water fountains clean, good repair, properly regulated −1
Observed build up/spills in water fountain in hall near ultra sound rooms and in main hall. Even though water fountains are not being used; keep clean. Replace damaged cover near mouth nozzle on water fountain on 5th floor.
Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed torn/damaged mattress in ACU bay 13. Observed damaged chair in 6th floor waiting room. Observed tape adhesive on (1)clean room mattress on 5th floor. (1) Torn/damaged pillow discarded at time of 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).
Mattresses shall be kept clean, dry, and odor free. 15A NCAC 18A .1319 (a).
Mar 5, 2020 98 / 100 · 2 violations
Inspector comments: General Comments:
#1. Thoroughly clean flooring under shelving in storage rooms/areas throughout ICU, 6A, 6C, Neuro ICU, CCU, 5A, 5D and 5F. ****Keep all flooring clean. See rule .1309 (a).
#3. Observed minor wall scuffing on walls throughout 3A, 4A and 6F, particularly in soiled utility rooms. Touch-up paint throughout rooms in behavioral units. Recaulk around back of toilets in ED. Tightly secure loose wall covering behind hand railing in hallway area. Tightly secure covering on door outside of CT. ****Keep all walls and ceilings clean and in good repair. See rule .1310.
#8. Observed discoloration and black residue on corner of shower in room 800. Observed hand washing sink and counter soiled in room 730. Observed leaking toilet in first floor public bathroom---> leaking toile addressed at time of inspection. Much improvement has been made since last inspection. ****Keep all bathing equipment clean and in good repair. See rule .1312 (a) and (f). **Keep all toilet equipment clean and in good repair. See rule .1312 (b).
#17.Observed minor build-up on the nozzles of water fountain throughout 3A, 4A and 6F units. Observed high water pressure on water fountain on 5th floor (5D). Adjust water pressure so water does not splash onto the floor. **Drinking fountains shall be kept clean and properly regulated. See rule .1314 (a).
#19.Observed pink residue on ice chute of ice machine in ICN (critical) ****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. See rule .1314 (b).
#28. Observed items on the floor in storage rooms under shelving throughout in ICU, 6A, 6C, neuro ICU, CCU, 5A, 5D, 5F. Minimize the amount of items placed in storage bins and on shelving to prevent items from falling onto the floor under shelving. ****All patient care or consumable items shall be stored at least 8 inches above the floor. See rule .1318 (a).
#33. Observed tape adhesive on clean sheet. Have CNA's to monitor for tape adhesive on clean linen when changing linen. Observed soiled linen on bed in ED.-----> Linen changed on bed in ED at time of inspection. ****Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. See rule .1319 (b).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed sticker residue on pillow, red stains on chair, and damage arm of chair in room 761. Observed torn/damaged cushion on chair in 7823. Observed sticker residual on pillow in 730. Thoroughly clean cracks and crevices of chairs with cushions throughout 7D and 7E. Observed torn mattress in ICU room 6. Observed soiled pillow in room D594. Observed worn mattresses on stretchers in ED and PED ED. Observed damaged mattress in isolation room in ED. Replace torn/damaged mattress. **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).
#36 · Approved utensils and equipment, cleaned and sanitized −1
Observed hair and paper in bottom of refrigeration unit in Nursery. Observed ice building up in freezer section of refrigeration unit in 7823. Defrost and clean freezer section of refrigeration unit often/regular! Observed freezer unit soiled in 7E nourishment area. Observed base of bin and interior top of microwave soiled in nourishment area of 5D. Observed refrigeration unit, drawers and cabinet area soiled in 5D neuro ICU and ICU neuro.(nourishment areas)
**All utensils and food contact surfaces of equipment used in the preparation, service, display, or storage of potentially hazardous foods shall be cleaned and sanitized prior to each use. 15A NCAC 18A .1320 (c).
Aug 29, 2019 97 / 100 · 3 violations
Inspector comments: #2. Observed debris on the floor in the clean utility room (7143) and spots on the floor in Labor and Delivery utility room. **Keep all flooring clean. 15A NCAC 18A .1309 (a).
#3. Observed staining on the ceiling tile in utility closet (7436). 3. PICU- Stained ceiling tile- clean linen room. Observed water damaged ceiling tile in closet area in (CVOR) in need of repair; Observed wall damage in resident room #5817 in need of repair.
**Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#10. Label bed pan in room C470.
21. Observed busted trash can in Labor and Delivery utility room.
**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).
#28. Observed soiled IV pole stored in med room 7F.
#33. Observed linen not properly covered in CCU soiled utility room. ACU & PACU- Biohazard: soiled towels stored in bin unprotected.
#34. Observed linen uncovered along with equipment in 7E along with other supplies. Observed uncovered patient clothes stored w supplies in all behavior health.
#35. Observed patient’s personal belongings in bag on floor intermingled in behavior health. Store personal belonging separated.
#36. Replace damaged gasket on nourishment refrigeration unit in H37. Replace damaged shelving in nourishment area in CCU. Clean top interior of microwave in CCU nourishment area. Defrost and clean freezer section of refrigeration unit in ICU. Observed interior of refrigerator in need of cleaning in the ED. Cleaned during the inspection. Observed cleaning needed in the bottom of the refrigerator.
**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).
General Comments-Observed bed in the hall with stained sheets and tape on the mattress.
#8 · Facilities conveniently located, clean and in good repair −1
#8. Observed shower wand with soiled handle and underside of shower chair soiled in ICU common shower area. Clean base corner of shower and regrout/recaulk corner of shower in C451. Observed hair and black build up around non slip in the tub in room 772. Needs to be cleaned. ACU- Nourishment- pink drains. Observed toilet seat very loose in resident room #584 in need of repair. Observed soiled vanity in room 7020. Observed hair in shower of room 718. Observed clogged toilet in 7E seclusion room. Observed soap holder with scum in room 7804. Observed shower curtain soiled in R793. **Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
#13 · Lavatory and bathing hot water between 100 and 116 F −1
Observed faucets not reaching proper temp (73F). Observed water temperature in room 7804 120F. PICU- sink in med room at 70-71F. Observed resident room #5805 having hot water at 121 F, Resident rooms in (5A) having sensor faucets not reaching proper temp (73F).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Replace worn over bed table and dust high fixture in dialysis. Observed chair with worn cushion in waiting area in ICU. Dust high fixture in 6129. Repair damaged cushion on chair in Neuro ICU. Observed debris in the grooves of the bedside table in PACU 21. Observed broken handle on cabinet drawer inside resident room #5817; Observed bed frame inside CVUR. Observed rusted bed frame in room 718. Observed dusty bed frames in seclusion rooms. Observed cracked over bed table in room 7827.
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).
Mar 21, 2019 96 / 100 · 4 violations
Inspector comments: See attachment.
#8 · Facilities conveniently located, clean and in good repair −1
Toilet needs to be cleaned in waiting area on 7E. Slow drain in 712. - Observed cleaning needed in hand sinks of soiled utility in Endoscopy and in soiled utility of radiology holding room. Observed rusted toilet supports in several restrooms throughout Endo, Radiology, and ED. Observed re-caulking needed behind hand sink of room 46 behavioral health ED and hand sink and toilet of D side ED restroom. Observed build up on shower curtain in rooms 5821 and C573. Observed tread peeling in D596 tub. Observed cracked/peeling surface of tub in C581 and C583. Observed water leaking from handle of sink in 5802. Observed calcium build up on shower head in C573. Observed loose toilet seat, hall dialysis unit.
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Refurbish or replace damaged furniture in waiting area at 7C and mother baby waiting area. Damaged mattress in mother baby area replaced at time of inspection. Observed build up on seams of mattress in room 631 in CICU. Linen were removed and mattress was cleaned. Handles broken off drawers at nursing station on 3rd floor in need of repair; Shelving in Med room 4th floor having dried fluids collected on bottom shelf in need of general cleaning. Observed ripped pillow in 785 (7D). Observed the head cushion of the eye stretcher in disrepair in OR B-side. The inside cushion is exposed in areas. Observed cushions torn on the Jackson table in the OR hall. Observed mattress with rips and tears in room 6 of D side ED. Observed peeling mattress in CVRU bay 6. Observed damaged/torn pillows in C581, 5802 and C583. Observed damaged cabinet shelving in 5C med room, damaged laminate in drawer of C583, cracked laminate at the vent in C581, broken cabinet hinge in D596, broken handle in 5F med room. Observed drawers in 5D med room in need of cleaning. Observed frayed chair seat C346 (dialysis). Observed torn pillows H36 (hospice).
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
Observed paint and disposables being stored in contact with clean linen in room 3 of nuclear medicine. Observed no cover over linen cart being stored with other items in behavioral health ED clean supply. Observed linen comingled with other items in cabinet of Bay 6 CVRU. Observed linen uncovered in 5D clean utility.
#36 · Approved utensils and equipment, cleaned and sanitized −1
Observed hair in fridge in 7818 (7F), catch pan of ice machine has build up (7E-IM), ice machine grate has build up in crevices in patient snack room (7E-IM), microwave with food residue in 7F oncology family room. - Observed cleaning needed in refrigerators of ED behavioral health med room and A side ED nourishment. Observed cleaning needed in microwave of radiology holding room nourishment. Observed 5F nourishment 2 room with spills and build up in microwave and refrigerator. Observed build up on gasket on refrigerator in 5C nutrition. Observed rusted shelving in refrigerator of 5D nutrition. Observed cabinets in nourishment room need cleaning, 6F. Crumbs underneath microwave on counter in nourishment room 3rd floor. Observed cabinets, and drawers with spills and coffee build up in 5F nourishment 2. Observed spill in freezer in 5D nutrition.
Sep 26, 2018 96.5 / 100 · 4 violations
Inspector comments: -#2. Observed soiled flooring in X-Ray room #1. Observed build-up in corner of flooring in nourishment room of 5F. Observed sticky floor residue in 7802.
-#3. Observed water stained/damaged ceiling and wall scuff in Argio intervention room. Observed door framing/jambs needing repainting. Observed wall damage in examine room #6 in radiology. Observed damaged ceiling tile in ICN clean utility. Observed damaged wall by window in C576. Observed wall piling in C572. Observed loose wall paper in bathroom of C545.
-#5. Observed vent covers in c379, H38 and 4SW storage dusty. Observed heavy dust build up on bathroom ceiling vents throughout 5C and C545.
-#9. Observed storage in neurosurgical ICU shower room. Storage removed from shower room at time of inspection.
-#12. Observed no paper towels at hand washing sink in soiled utility room in OR and PEDS. Paper towels provided at time of inspection.
-#13. Observed water temperature at hand washing sinks throughout ICU (A) 90F. Water temperature corrected at time of inspection.
-#18. Observed water pitcher not labeled in C572, 7807.
-#26. Observed flies in soiled utility room in 3rd floor Hospice. Orkin contacted and soiled utility room at time of inspection.
-#31. Observed feeding tube bag in use in C654 not labeled or dated.
-#34. Observed gum stain on sheet in 5803. Observed personal front clothes washer machine in behavior health soiled 7EIM. Observe shelving bracket stored on linen storage shelving with clean linen. Sheet rock dust was also present on shelving.
#8 · Facilities conveniently located, clean and in good repair −1
Observed discoloration around drain in hand washing sink in 762. Observed hair in hand washing sink in room 870(clean and unoccupied room). Observed soiled shower curtain in D694, 730 and 731. Observed hand washing sink in Bio Hazard room in neurologically ICU blocked. Observed slow draining hand washing sink in ICU waiting room bathroom. Observed damaged foot pedal on hand washing sink near nurse station in ICU(A). Observed soiled hopper and hand washing sink in OR soiled utility.
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).
#28 · Adequate storage, area clean, items properly stored −0.5
Observed spilled drink in bottom of nourishment cabinet in 5F. Observed storage on the floor in neurosurgical ICU storage closet. Observed employee drink stored near clean equipment in vendor drop off room for clean equipment/supplies. Keep storage areas clean. No storage onthe floor.
All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed rust on bed under mattress in 762, 774, 5809, 7802 and 7803. Observed facing on hand washing sink counter damaged in radiology area. Observed soiled mattress in adult endo room 34. Observed soiled cabinet in behavior health nourishment area. Observed damaged pillow in 5809. Observed underside of over bed table soiled in 5809. Observed base of IV pole soiled in clean utility 7E. Repair molding on over bed table in C483 or replace. Repair back splash behind hand washing sink in 4C med room. Repair hinge on cabinet door in C679. Observed rusted transfer cart to hold surgical equipment in OR. Observed some debris under mattress in PED. All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
#36 · Approved utensils and equipment, cleaned and sanitized −1
Clean nourishment refrigeration unit in 5F. Observed microbial growth on interior of refrigeration unit in 5C. Observed single service cups not covered in behavior health(7EIM). Observed damaged gasket on refrigeration unit in 7F nourishment. Observed damaged door handle on refrigeration unit in neurosurgical ICU med room. Clean and defrost nourishment refrigeration unit in CCU.
Non-food contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. See rule .1320 (c).
Apr 11, 2018 93 / 100 · 4 violations
Inspector comments: #2. Clean floor in soiled utility in ICU and hospice. Observed floor dusty and debris present in soiled utility in oncology.
#3. Secure loose corner of wall paper near hand washing sink in C664. Observed stained ceiling tiles in dialysis bay 5 and bay 8 near the light. Observed wall damaged in soiled utility 6A and 538. Touch up paint in dialysis storage, 538, 6A soiled utility, IV room 6A. Clean wall in soiled utility on B side of OR. Touch-up paint wall in H31. Touch-up paint door framing to rooms throughout. Repair wall beside refrigeration unit in family kitchen in PED’s. Repair wall beside crib and refrigeration unit in 215.
#4. Observed dim lighting less than 10FCU in seclusion room in 6D behavior health.
#5. Observed top of light fixtures soiled/dusty throughout in rooms and bathrooms.
#9. Observed several toilet riser/chairs stored in tub room in NSICU.
#12. Observed no soap at hand washing sink in exam room in 7D.
#13. Observed hot water temperature 67F-75F at hand washing sink in patients room 7D. Observed water temperature 118F in 869, 120F in 868.
#14. Observed showers being cleaned and disinfected once a day in double occupancy room. Clean and disinfect showers between different patients.
#17. Observed high water pressure on water fountain located on 5F.
#18. Observed unlabeled water pitchers in room 5806, 5829 and C572.
#28. Observed patients personal belonging stored on the floor in closet in 7E.
#33. Observed stained sheet in dialysis bay 12 and 612. Observed soiled linen not covered in OR on both A and B side. Observed soiled sheet on bed in 729, 772,803 and PACU.
#34. Observed soiled linen bin not labeled in soiled utility on 5D. Observed clean linen uncovered in clean utility of special maternity. Observed gloves and other items stored on clean linen within clean linen bin.
#8 · Facilities conveniently located, clean and in good repair −1
Observed shower curtain and underside of toilet soiled in C664. Secure loose laminate on back splash behind hand washing sink in nourishment room in 6F. Observed stained shower curtain in 527 and pink build up on showerhead in 612. Observed rusted sink drains in hand washing sink between 12 and 13, 5A med room, 5A nourishment room and CPPU. Observed hopper soiled in soiled utility in PED’s b hall. Observed slow hand washing sink drain in 5803. Observed loose non slip strips in base of bath tub and damaged shelving in C566. Observed soiled shower curtain in 6D behavior health. Observed soiled toilet seat in 729. Re-grout base floor of shower in 762. Repair or replace crack shower tile in 868. Clean under shower chair in 869. Clean under toilet seat in 838.
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed rusted bed in dialysis bay 12, 538 and 612. Observed worn beside table and damaged furniture in 5A family waiting. Observed tape and tape residue on mattress in B5. Observed damaged cushion on knee portion of the “Andrew” frame on A side of OR. Tighten loose handle on cabinet in H31. Observed damaged chair in H44. Observed damaged pillow in 209 ,PED’s,762 and 796. Observed rusted baby cribs in NICU. Repair damaged cushion on chair in 868. Observed stained cushion on cushion in 869. Observed rusted bed framing in 772. Clean stain on curtains in PACU. All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
#36 · Approved utensils and equipment, cleaned and sanitized −1
Observed damaged gasket on refrigeration unit on nourishment refrigeration unit in NSICU. Observed pink microbial growth on ice machine chute in nourishment area of recovery in PACU. Observed shelving soiled in nourishment area of PACU. Clean cabinet doors in family room. Observed area under microwave soiled in ICU, 3C and hospice. Observed shelving, microwaves, refrigeration units and area under coffee maker soiled in nourishment center on 5C, 5D and 5F. Observed front of cabinet area soiled in 6D. Observed general cleaning on cabinet doors and shelving in nourishment center on 7th floor. Clean base of bins in nourishment rooms. Detail clean breast milk refrigeration unit in med room of women services. Clean refrigeration unit in nourishment refrigeration unit. Clean interior of microwave in nourishment room of special maternity.
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).
#42 · Food protected. Potentially hazardous food maintained at 45 F or below, or 140 F for above, consumed or discarded within 2 hours of being removed from temperature control −4
Observed sandwich in dialysis nourishment refrigeration unit 51F. Observed sandwich 53F in 5A nourishment. Observed several sandwiches in 5F 50F. Observed moldly container of jello in nourishment refrigeration unit in B 5D. Observed patients food on tray stored within the splash zone in nourishment area on 7E. 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).
All food while being stored, prepared, transported, displayed, and served, shall be protected from contamination. 15A NCAC 18A .1323 (a).
Nov 30, 2017 95 / 100 · 4 violations
Inspector comments: Observed faucets leaving water on for less than 15sec in behavioral health units. Longer water running times will allow for more effective handwashing.
4) Observed light not working in nourishment room of special maternity.
1) Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b). Repair transitional molding at entrance to 595D. Observed missing floor tiling in 7C soiled utility room.
2) Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed floors with heavy dust and debris accumulation throughout 6D, 7D, and 7E. Clean floor in medroom in 5C and clean floors throughout 5C.
3) Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed missing ceiling tile in NICU food cart room. Observed stained ceiling tiles in NICU food cart room. Continue to touch up paint throughout 5th floor (hallways, storage). Thoroughly clean wall in soiled utility in 5F. Monitor and repair ceiling in 595D bathroom.
10) Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c). Observed unlabeled bed pan in 5809.
11) Observed handwash sink being used as dump sink in 7C soiled utility.
17) Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a). Observed low pressure from water fountain in 6C.
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 OR and Endo soiled utility rooms with waste not properly contained.
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 sheet on bed in 735. Observed torn sheets in 697, 785, 735.
40) Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply and shall be labeled with the name of the person to receive the food and the date the food was brought into the facility. 15A NCAC 18A .1321 (b). Observed opened patient drink stored above stock food in refrigerator. Observed employee food dated, but not labeled in 5C refrigeration. Ensure employee food is labeled with name and date.
43) All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b). Observed broken thermometer in nourishment fridge 6C.
All refrigerators shall maintain a temperature of 45°F or below. 15A NCAC 18A .1323 (b). Observed fridge in imaging holding at 50F.
28) Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furni. Observed heavy build up under coffee machine head in PICU and Peds nourishment rooms.ture, and supplies, and kept clean. 15A NCAC 18A .1318 (a).
12) Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). Observed soap dispenser to be damaged in 730. Observed no papertowels in room 852. Observed soap dispenser not working in OR side B soiled utility room
#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 cover on pipe leading to wall to be loose on toilet in unit 6D. Observed leak at hopper in 6F. Observed hopper in 7C soiled utility room in need of cleaning.
Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Caulk corner of shower in 595D. Loose anti slip strips in tubs rms 379 and 354. Observed missing grout in shower of 802.
Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b) Observed nurses station handsink/vanity area in disrepair in 6A.
#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 build up on metal frame of bed in 730. Dust top of cabinet in 5805. Observed chipped laminate on cabinet in 5805. Repair or paint area. Observed 8th floor courtyard patio table to be rusted. Observed worn and damaged seat vinyl in the NICU waiting room. Observed tape under bedside tray in peds procedure room. Observed tape on beds and clean equipment in OBSI, halls, and storage rooms in OR. Observed torn arm chair in PICU room 5. Observed dust build up throughout fixtures.
#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 interior wall of refrigeration to have build up in 5A nourishment room. Soiled microwaves throughout. Ensure items are on a regular cleaning schedule. . Observed soiled microwaves in peds family kitchen and PICU nourishment room. PICU nourishment room drawers were heavily soiled. Observed heavy build up under coffee machine head in PICU and Peds nourishment rooms.
#42 · Food protected. Potentially hazardous food maintained at 45 F or below, or 140 F for above, consumed or discarded within 2 hours of being removed from temperature control −2
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 milk in ICU nourishment fridge holding at 49F. CDI: Refrigeration was turned down. Milk was voluntarily discarded. Observed ham sandwiches at the nurses station holding at 52F. CDI: Sandwiches voluntarily discarded.
May 9, 2017 96.5 / 100 · 4 violations
Inspector comments: 3. Observed ENDO hallway and ENDO area with damaged walls and doors. Observed wall with residue and damaged wall paper in Mother Baby room 874. Damaged wall at mop sink in PEDS soiled utility near the OR. Damaged door handle at sterile room in OR. Damaged walls observed throughout OR area. Damaged wall bumper at bay 17 in OR recovery. Damaged walls in 353 and 356. Loose baseboard in 366. Keep all floors, walls, and ceilings clean and in good repair. 5. Observed vents in need of cleaning in PEDS 229, 215, throughout radiology, 3C, 4C, 5A, 6A. Keep vents clean and in good repair. 10. Observed bed pan with no label in 5F 5801. Label all bed pans with the patient’s name and date the pan was issued. 12. Observed nourishment rooms in need of hand sanitizer in 5D and 6D. Observed 7D soiled utility room in need of hand sanitizer. Observed no paper towels in ENDO soiled utility room. Maintain soap and disposable towels in at all sinks. In rooms constructed prior to 2003, provide hand sanitizer when sinks are absent. 13. Observed hot water in room D589 at 118 F. Observed hot water at 96 F in PEDS 229 and 344. Maintain hot water between 100 -116F. 17. Observed water fountain near PEDS 210 with residue. Keep all water fountains clean. 24. Observed fruit flies in 3C nourishment. Keep the facility free of pest. 33. Observed sheets with residue in PEDS 229, ENDO bay 26, Room 800 Mother Baby, Labor and Delivery C-Section room 2. Sheet with hole in PEDS 215. Replace linen when damaged and when residue is observed. 34. Clean linen exposed at cart in hallway on 5F. Keep linen protected in all multi-use areas. 35. Observed a damaged OR table pad in CVOR room 2. Damaged arm rest on wheel chair in OR Recovery. Damaged padding on split leg attachment in OR storage area. Observed mouthable toys being cleaned with a disinfectant. Keep all patient contact equipment clean and in good repair. 42. Observed milk being held at 48 F in 4C nourishment. Maintain potentially hazardous foods at 45 F or below or at 135 F and above. 43. Damaged refrigerator thermometer observed in Radiology RN holding area. Observed 4C nourishment refrigerator holding temperature at 48 F. Maintain thermometers in good repair. Ensure refrigerators maintain the air temperature at or below 45 F. 36. Observed microwave and refrigerator in need of cleaning in 5F nourishment room near 5815. 7F microwave in need of cleaning. Refrigerator in need of cleaning in PICU A hall. Dietary Cart interior in need of cleaning in Mother Baby Area. Keep all food service equipment clean.
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#8 · Facilities conveniently located, clean and in good repair −1
Observed hand washing sinks blocked in 5F and Cath Lab Soiled Utility, CVOR holding area. Observed a new soiled utility room with no handwashing sink on 7E. Sink in need of cleaning in 7E activity room. Observed laundry equipment with residue and debris in 6D. Showerhead with residue 7C 755. Shower with residue in room 443.
Handwashing sinks shall be accessible to all areas where personnel may be exposed to bodily excretions or secretions. 15A NCAC 18A .1312 (d).
Handwashing facilities shall be provided in kitchens, food preparation areas, sterile supply processing areas, medication rooms, laundry areas, and soiled utility rooms. 15A NCAC 18A .1312 (d).
Keep all sinks, laundry, bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
#19 · Ice protected, dispensed, equipment clean in good repair −1
Observed ice machines with residue CVRU, 7F, 7C, labor and delivery nourishment, Cath Lab medication area, CPPU nourishment, PIC, Mother Baby Family Care area, 4C. Observed an ice machine being cleaned with a non-food grade cleaner. Use an approved food service cleaner and sanitizer when cleaning ice machines. Repeat Non-Compliance
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).
#28 · Adequate storage, area clean, items properly stored −0.5
Observed damaged shelving and shelving in need of cleaning in 5F nourishment room near 5815. Observed patient storage at sink in room C569. Observed a cup dispenser with no lid in 5D med room. Observed chemicals stored above or with patient care items in OR recovery storage, 5D, PEDs procedure room, and 5C. Storage on floor in 7E storage room, 1st floor X-Ray supply room. Observed cabinets in need of cleaning in PEDS family kitchens. Observed 7C clean supply room bins collecting debris. Body positioning board stored on the floor OR 6B.
All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed beds with rust in 5F 5822, PEDS 229. Damaged cabinet in room C569. Observed red residue at lab table in CVOR room 2. Observed a piece of equipment in CVOR room 2 with chipping paint. Observed cabinets throughout PEDS with minor damage. Observed damage curtain near ENDO bay 23. Observed mattress with residue 7C 755, PEDS ED 2. Damaged pillows in Mother baby room 869. Crib with damaged paint in OR recovery. 6F room 6825 with damaged laminate at couch. Damaged waiting room chairs in Ultrasound waiting room. Bedside table with residue Radiology holding bay 2. Blinds in 480, 443 in need of cleaning. Damaged couches in room 527, 603.
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).
Oct 4, 2016 96.5 / 100 · 4 violations
Inspector comments: 3. Observed the following: Walls in need of minor repair on 6th and 7th floors. Intensive Behavioral Health isolation room walls with residue. ED care station D with a damaged wall and tape on the wall.Damaged ceiling tiles in NICU near charge nurse desk. Damaged ceiling in Nuclear Medicine room 5. Damaged wall in High Risk OB clean storage room. Keep walls and ceilings clean and in good repair.13. Hot water in Dialysis unit observed at 91-97 F.Maintain hot water between 100-116F.17. Water fountain observed with black residue on PEDS North Hall. Observed water fountains with high water pressure on 7C, 3C, and 6C. Keep water fountains clean and in good repair. 21.Dumpster area observed with loose trash.Keep the dumpster area clean. 32. Observed the following: Bed frames observed with rust in PICU room 1, PEDS room 208, 4C 443. Missing drawer handle in room 5C room 540. Stained mattress in room 5D room 585. Damaged mattress room 852 Labor and Delivery. Residue under mattress in 871 Labor and Delivery. Debris collecting under a mattress in Mother and Baby nursery. Day bed with debris in room 816 Mother and Baby. Keep all furniture in good repair. 33.Observed soiled linen not in a covered container in a PEDS soiled linen room, Labor and Delivery soiled utility, Mother and Baby soiled utility. Stained pillow case in 5A room 524, 7C 754. Keep all soiled linen stored in a covered container. 34.Observed uncovered clean linen stored on a chair in 5F storage room. Keep clean linen covered. 40.Observed food of patients no longer present in 4C nourishment. Observed opened personal milks stored back in the refrigerators in 6C and 6A nourishment rooms. Discard patient food once they are discharged from the hospital. Do not place food that has been partially consumed with unused food items. 43.Observed a damaged thermometer in 5D nourishment room.
#8 · Facilities conveniently located, clean and in good repair −1
Observed the following: Shower curtains with residue in Behavioral Health and in PEDS room 208. Shower head with residue in Intensive Behavioral Health common shower room. Damaged shower wand in room 6817 6F. Sinks observed blocked from use in ACU soiled utility room, 5F clean and soiled utility, CVR bio hazard room. ED hopper at care station A with residue. Pink residue observed at Adult ED room 7 sink. Tub faucet leaking in room 7C 754. Shower head leak 4C room 443. Leaking sink faucet in 3C Hall Bathroom. 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). Handwashing sinks shall be accessible to all areas where personnel may be exposed to bodily excretions or secretions. 15A NCAC 18A .1312 (d).
#19 · Ice protected, dispensed, equipment clean in good repair −1
Ice machines with residue in ACU nourishment area, Adult ED care station D, 6C nourishment, 4C medication room. Observed screws protruding into the ice dispensing area in 3C Overflow nourishment, Dialysis nourishment clean supply. 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).
#28 · Adequate storage, area clean, items properly stored −0.5
Observed the following: Clean supplies observed at in ACU clean storage area. Toilet paper observed under sewage line in PACU room 21. Clean items stored less than 8 inches above the floor in the PEDS North Hall clean supply room, 5F storage room 1 and 5C equipment storage. 5A PT wound cart with residue. Observed cabinets with residue in 6A nourishment room. Observed used patient care items left on a countertop with clean supplies 4C central supply and 3C medication room. Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a). All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a).
#36 · Approved utensils and equipment, cleaned and sanitized −1
Observed the following: Refrigerators with residue, 7F nourishment, Labor and Delivery, 7C Medx room, High Risk OB nourishment. Damaged gasket on refrigerator at PICU nourishment area. Observed microwaves with residue HVI vending lobby, 5A nourishment, 5F nourishment 1, 7C nourishment. Coffee machine with residue Mother and Baby nourishment room.
Non-food contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. See rule .1320 (c).
Apr 12, 2016 97.5 / 100 · 3 violations
Inspector comments: Observed the following:
2. 7 EIM with dust on floor behind laundry machines. 8th floor OR storage room floor with debris. Keep all floors clean.
3. 6D D685 ceiling damaged in bathroom and around vent. 7E wall damaged in main sitting area. 3C C355 with damaged wall. Loose wall paper 5A room 35 shower. Repair leak around window in 5A storage room. NICU storage room with damage ceiling. Keep all ceilings in good repair.
5. Vent with dust in 6A 614. Keep all vents clean. 6D D685 residue on curtain. Keep all curtains clean.
8. 6F room 6818 shower with residue. Slow draining sink in ED care station A med room. Observed toilet support stands in ED with rust. 7E med room, 5A room 35 with leaking faucets. ICU soiled utility with debris in the sink. 5D 594 toilet with residue. Hopper collecting residue in CVRU soiled utility. Soiled diaper changing table in 7th floor gallery lounge. Keep all toilet , handwashing and bathing equipment clean and in good repair.
9. 6C nourishment room ice machine with residue. Keep all ice machines clean.
12. OR A soiled utility with no paper towels at hand washing sink. Clogged soap in dispenser 7EIM soiled utility room. Keep all sinks stocked with soap and disposable towels.
15. Damaged backflow prevention bell in NICU soiled utility room. Keep all backflow equipment in good repair.
24. Large spider observed in Pediatrics medication room.
33. Open bag of soiled linen in 6A soiled utility. Label soiled linen bins in ED. Keep all soiled linen covered and in a labeled container.
34. Medical transport pods stored with clean linen CDRU. Avoid storing non-linen items with clean linen.
30. 6F, ICU, 3C, 5C medication room pill crushers with residue. Keep all pill crushers clean.
43. Damaged thermometers in multiple 8th floor nourishment rooms. Keep a functioning thermometer in all refrigerators.
#28 · Adequate storage, area clean, items properly stored −0.5
Observed the following: 6th floor CICU nourishment room cabinet with debris. Chemicals stored with patient care items in hallway closet on 6A. Patient care item stored next to sink in 6A nourishment room. ED B med room, 5th floor CATH Lab, 5D med room with cups not properly covered. 7E laundry with debris on the shelves in cabinets. 3C medication room with supplies on the floor. Pediatrics clean supply with multiple clean items on the floor.
Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a).
All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed the following: Damaged chair in 6th floor NSICU room 3. Damaged cabinet handle and couch in 6F 6818. Bed frame with rust in 6A room 614, 870, and 878. OR A clean storage with beds collecting residue. ED A room 9 bed frame collecting trash inside the frame due to missing caps. ICU room 6 with damaged mattress. Damaged linen on mattress in Dialysis. 5F nourishment cabinet with residue. 5F nourishment with water damaged cabinet door. Damaged over bed tables observed throughout 5th floor. Cath Lab body positioners collecting residue. CPPU Exam room 19 with a damaged mattress. Rusty tables on balcony 8th floor family care. Family care infant observation room with damaged wooden beds. All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
#36 · Approved utensils and equipment, cleaned and sanitized −1
Observed the following: 6th floor CICU, 6C, ICU, 5C nourishment refrigerators with debris/residue. Damaged drawer in 6F nourishment room refrigerator. CVOR refrigerator with residue on the gasket. Coffee machine in Tucker’s waiting room. Non-food contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. See rule .1320 (c).
Dec 17, 2015 97.5 / 100 · 2 violations
Inspector comments: 2. Observed the following: Dust on floor in 7E904, 7E Laundry, Shower floors with residue 7E 932, Women’s Health room 869. Damage floor 7E 923. Keep floors clean3. Observed the following: Wall damage 7E 923. Baseboard tile damaged at entrance to Women’s Health and entrance to NICU main hand washing area. Repair walls in Bio Hazard rooms and storage rooms in Women’s Health. Minor wall damage in patient rooms on 6th floor. Missing shower towel 5A 533. Keep walls clean and in good repair. 8. Observed the following: Loose rub non-slip strips 7E 913. Sink with residue 7D restraint room. 6A med room with slow draining sink. Keep bathing and handwashing equipment clean and in good repair. 9. Observed the following: CCU tub room with a wheel chair. Keep showers and bathing rooms free of storage. 11. Observed the following: Utensils stored in a nourishment room sink 5A. Keep hand washing sinks free of storage. 13. Observed the following: Hot water at 117.5 F in Adult ED-D room 6. Hot water within Nursery A and B at 94F. Maintain hot water between 100 - 116 F. 18. Observed the following: Water pitchers were not labeled 7E 909, 5A 535, 5F 582, 5C 579. Label water pitchers with the patients name. 28. Observed the following: Storage less than 8 inches above the floor in the main EVS storage area, CATH lab. Cabinet trays collecting debris in the PEDS nourishment area cabinet. Personal care items and phlebotomy items stored on a toilet and next to the sink in Adult ED-D room 6. Cups exposed to contamination in nuclear med room 1, Tucker Waiting room and medication rooms in Women’s Health, cups on floor in 6F storage. CCU equipment stored on the floor in a clean supply room. Chemical wipes stored with clean items in nuclear med room 1. Provide clean and approved storage for all patient related items. 33. Observed the following: Soiled pillow case 7E 923, 7D 694. Soiled 7E 904. Soiled linen not bagged in OR A bio hazard room, 5F soiled utility. Soiled linen on bed in hallway was not covered near Cardio Noninvasive. Properly store all soiled linen. 34. Observed the following: Personal phone and personal drink stored with clean linen in the main clean linen storage room. Bed with clean linen exposed to contamination OR B. Properly handle and store clean linen so that it is not exposed to contamination. 35. Observed cleaned shower chair with residue in 3C storage room. Properly clean all patient contact items before placing the items in clean storage. 36. Observed the following: Rusted shelving in Women’s Health clean utility room 2 refrigerator. Freezer in NICU special care, 6 C nourishment freezer with residue. Microwave with residue 5A and CPPU nourishment. 4C nourishment refrigerator with residue. Keep all food service equipment clean and in good repair. 39. Observed 3C and 5th floor sandwiches with inaccurate date due to date machine error. Products observed with day and year on label. Error corrected during the inspection.
#12 · Lavatories have mixing faucet or tempered water, soap hand towel and hand drying device −1.5
Repeat Non-Compliance: Observed the following: Empty soap dispensers in PET soiled utility, Adult ED-D soiled utility, 7E soiled utility, OR A Bio Hazard room. 6B waiting room with no paper towels. 5 D nourishment area needs hand sanitizer. Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed the following: One damaged pillow in an Endoscopy procedure room, 7D 797, 7D 694. Stretchers with minor surface damage and tape residue in Adult ED-D room 9, PEDs ED room 3, Adult ED-A room 15, OR B. Room 800 Women’s Health, PACU 19, OR B, OR A hallway, PICU OBS1, Pediatrics treatment room with tape residue on mattress and beds. Damaged mattress 7E 932, PACU 20, OR B. Damaged arm rests on chairs and wooden bassinets throughout Women’s Health. Dust collecting on top of cabinets in Women’s Health. Clean door on Women’s Health non-food ice machine. Rusted bed frames in 5A 508, 5A 533, 5C 583. Damaged chair 5A 508. Laminate at sofa damaged 5F 582. 5F and 5C nourishment cabinets damaged. Room 841 cabinet damaged. All furniture, mattresses, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319
May 20, 2015 96 / 100 · 4 violations
Inspector comments: 1. Observed 5C C574 floor damaged. ENDO floor damaged near hand washing sinks. Hallway floor tiles damaged near waiting room at Maternity area. Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b). 3. Observed window sill damaged in 7E 930. 5C C553 wall damaged near toilet. Repair wall at Birthing Center nourishment and housekeeping closet. Clean wall behind coffee dispenser in Labor and Delivery area. Ultra Sound rooms 2 and 3, X-Ray, Nuclear Med room 3 with wall damaged. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.4. Observed 6F light not functioning in shower room 6806. All areas shall have sufficient illumination. Maintain 10 foot candles of light at 30 inches above the floor in all areas other than food service areas. 15A NCAC 18A .1311 (a). 5. Observed HVAC vent with dust and debris in 4C C454. Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).10. Observed bed pan being washed in a restroom without a spray rinse toilet in ENDO area. Unlabeled bed pans in 6A room 620 and 7F room 7806. Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c). 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).15. Observed backflow missing from Portable RO unit water lines on 3D. Observed 6C EVS closet backflow prevention device missing the bell cover. Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).18. Observed a water pitcher not labeled with patients name in pediatrics room 214. Label all disposable water pitchers with the resident’s/patient’s first name and last name. 15A NCAC 18A .1314 (a).21. Clogged floor drain and residue collecting at dumpster area. Solid waste containers, rooms, or designated areas shall be kept clean. 15A NCAC 18A .1316 (c).33. Soiled sheets in 6D 698 and 694. Observed soiled linen bin with no label in Pediatrics observation room. 5A soiled linen room and ENDO soiled utility with exposed soiled linen. 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).36. Observed microwave collecting residue in 3C, 4C, Hemby Theatre nourishment rooms. 4C and Hospice refrigerator collecting residue. 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).42. In 3C nourishment observed pre-made sandwich with discard date of 5/18/15. Observed food stored under sewage line in 3C storage cabinet. All food while being stored, prepared, transported, displayed, and served, shall be protected from contamination. 15A NCAC 18A .1323 (a).43. Damaged thermometers in nourishment refrigerators on 6C and 7F. All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b).
#8 · Facilities conveniently located, clean and in good repair −1
Observed hot water button stuck in staff restroom on 6D. Shower grout with mold and vanity missing edging E904 on 7E. Ring of residue observed in 7E 930. Push button faucets throughout behavioral health with short run times. Observed loose toilet seat in 3D patient restroom. Loose bath hand rail and a slow draining sink in Pediatrics room 221. Observed sink blocked in pediatrics soiled utility room. 5A A513 slow draining sink. Vanity cabinet damaged in 5A A512 and A513. ENDO custodial room being used as soiled utility. A hand washing sink will be required in this area since this is a new change. Toilet, handwashing, and bathing facilities must be conveniently located and readily accessible to residents and staff. 15A NCAC 18A .1312 (a). 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).
#12 · Lavatories have mixing faucet or tempered water, soap hand towel and hand drying device −1.5
Repeat Non-Compliance. Observed Hospice soiled utility room, 1st floor Ultra Sound Room 3, Radiology Holding soap dispenser not functioning. Paper towels missing at sink Ultra Sound room 4 on 1st floor. Sterile processing and decontamination area missing soap and disposable towels at all hand washing sinks. Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). Observed Blume play room hand washing sink with no hot water. All lavatories shall be supplied with hot and cold running water through a mixing faucet, or with tempered warm water. 15A NCAC 18A .1312 (d).
#28 · Adequate storage, area clean, items properly stored −0.5
Observed the following: 3C 363 with patient care items stored at sink. Personal drink with supplies on housekeeping cart on 3C. 3C med room bin with debris. Chemical stored above clean items in 4C med room. Med room cabinets collecting tape residue in Hospice Med room. Drawers collecting debris and residue in 3C nourishment. 5F med room disinfectant wipes next to medications. Single service cups on floor in supply room floor 1st floor diagnostic x-ray. 6A EVS closet with bag of clean pillows stored on the floor. ED clean supply room with catheters left on the floor. ED care station C with patient contact items on the floor. Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a). All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed rusty bed frames in 3C C381, C371, beds in 3D, 4C C457, Pediatrics 215, 221, H37, 5D 586 and 594, 5F 5814 and 5807. Bed with residue in 3C C381. 4C C457 room locker with rust. Couch with debris- 3rd floor hospice H37. Sheet with holes on a pediatrics procedure table. Pediatrics room 215 cabinet at refrigerator collecting residue. OR room A3 with torn mattress. ENDO room 7 with torn pillow. OR 013 with tape on bed rails. Used IV caps left on countertop in a room that hand been cleaned in ACU bay 27. Dust on high fixtures Maternity room 803. Hair dryer cord with residue Maternity room 803. Observed bassinets in Maternity and NICU with worn surfaces. Maternity 844 with damaged seam birthing mattress. 1st floor CT mattress damaged. All furniture, bed springs, mattresses, sleeping mats, other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
Dec 11, 2014 95 / 100 · 5 violations
Inspector comments: 1. Damaged floor in OR B6. Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b).2. Floor soiled in 7D closet. Keep all flooring clean. 15A NCAC 18A .1309 (a).3. Soiled and damaged shower ceiling in room 7E 925. ED oxygen room wall damaged. Walls in need of cleaning and Pediatrics soiled linen room and ED room 15. Handrail with chipping paint near Radiology. Observed water damaged ceiling in isolation dressing room in ED. Fluoroscopy room with water damaged ceiling. Endoscopy room with water damaged ceiling. Room 631 with damaged wall on 6A. Shower ceiling damage 6F, 6808. Wall damaged in 5D room 589. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.4. Observed a breast feeding with a non-functioning light in the NICU. All areas shall have sufficient illumination. Maintain 10 foot candles of light at 30 inches above the floor in all areas other than food service areas. 15A NCAC 18A .1311 (a). 5. Observed vent boxes with debris in 3C, rooms 361 and 353, 4C room 459. Observed dusty ceiling vent in 7D patient room. Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).11. Per staff pill crushers in ED are being washed at hand washing sinks. Except for the stipulations stated in rule .1312 (d), handwashing sinks shall only be used for handwashing. 15A NCAC 18A .1312 (d).13. Observed hot water at 85 F in 3C. Hot water 118 F in 876 Labor and Delivery. 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).15. Observed 6C and 6D ice machine drain line with no air gap at drain line. 6E wall spigots in patient rooms need backflow prevention. Backflow damaged at can wash in Labor and Delivery, Special Maternity, NICU housekeeping areas. Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).18. Observed 6C, room 656 water pitcher not labeled. Label all disposable water pitchers with the resident’s/patient’s first name and last name. 15A NCAC 18A .1314 (a).21. Observed debris collecting a dumpster area. Observed trash bin overflowing and trash on the floor in 5F soiled utility. 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).33. Observed a bed with debris in Hospice room 38. Observed stained linen and misc. items on a clean bed in a 7D room. Observed damaged clean linen in room 508. C570 with stained pillow case. Observed small soiled linen containers not labeled throughout 5th floor. Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).35. Soiled and stained positioning blocks observed in Radiology. Observed staff drop clean equipment on the floor on clean side of sterile processing and then the equipment was placed back in a bin that was to be sterilized. Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).39. Observed out of date sandwiches in ICU A, 6F nourishment room refrigerators. Observed use by dates on some sandwiches in nourishment rooms not readable. All food and food supplies provided by an institution shall be from sources that comply with 15A NCAC 18A. 2600.42. Observed milk cartons being delivered to nourishment rooms without temperature control. Milk needs to be placed back under temperature control after quickly after being removed from refrigeration. 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).
#8 · Facilities conveniently located, clean and in good repair −1
Observed a shower floor with residue at the drain in 3C, room 341. Observed sinks blocked in ICU B side soiled utility room and Hemodialysis clean utility. Observed a laundry room on 7D in need of hand sanitizer. Observed old soap tray on wall in a 7D room damaged. Observed a shower in need of re-caulking in a 7D room. Observed 7E day area sink in need of re-caulking. Leak under sink and damaged shelving in biohazard room, Care Station B in ED. Hot water not functioning at sink 6D, hall restroom. Damaged caulk at 6A med room sink. Pink residue a locker room drain Neuroscience ICU. Used bar soap left in a cleaned bathroom in Pediatrics room 211. Keep all handwashing, toilet, and bathing equipment clean, in good repair, and accessible. 15A NCAC 18A .1312.
#12 · Lavatories have mixing faucet or tempered water, soap hand towel and hand drying device −1.5
Repeat Non-Compliance: Observed soap dispensers nonfunctioning in Hospice medication room and soiled utility room, NICU Isolation, labor and delivery medication room, 7th floor, 1st floor, 5821, 508. No soap at sink in Pediatrics playroom. Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d).
#28 · Adequate storage, area clean, items properly stored −0.5
Observed a food product stored under sewage line in the 3C nourishment room. Observed nourishment room cabinets collecting residue in 3C, Hospice Pantry, ICU A and B. Observed a chemical stored above patient contact items in Hemodialysis clean storage room, ICU equipment room A, 7F clean equipment room. Observed patient care items less than 8 inches above the floor in 7C clean utility. Observed radiology storage closet with storage on the floor. Observed single service cups exposed to contamination Endoscopy waiting room, 6A nourishment. Observed clean supply storage containers with debris through 5th floor. Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a).All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed beds rusting in Hemodialysis, Hospice room 35, 4C rooms 454 and 459, 7C room 772. Observed a damaged couch in Hospice room 35. Observed an artificial nail on a couch in room 16, room was a clean. ED room 34 with dust on top of TV. Debris under couch cushion room 6810 6F. Damaged lamp and damaged chair in 5th floor waiting room. Damaged chair in room 5824. Damaged mattresses in room C570, ACU 13, OR room B6All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
#36 · Approved utensils and equipment, cleaned and sanitized −1
Observed the microwave in the 3C, ICU-A nourishment room collecting residue. Observed Hospice family room coffee machine collecting residue. Observed a refrigerator in the hospice pantry and 7F nourishment collecting residue. Observed oven drawer collecting residue in the Hospice family room. Observed a damaged freezer gasket in Hospice pantry. Observed a refrigerator with a damaged gasket in Hospice room 38. Observed drinking cups exposed to contamination on a meal cart on 3C. Freezer with heavy ice accumulation in RadiologyAll 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). Cooking surfaces of equipment shall be cleaned at least once each day. 15A NCAC 18A .1320 (c). 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).
May 1, 2014 93 / 100 · 7 violations
Inspector comments: 1: Floor damage in the 5A/5C Waiting Room restroom. Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b). 2: Dust on the floor in the Electric room between 6A and 6C, Respiratory Storage on 6th Hall, and Equipment room floor. Floors dirty at the 7 Floor NICU Storage room. Keep all flooring clean. 15A NCAC 18A .1309 (a).3: Baseboard tile damaged in 601 restroom. Missing baseboard in the pump room between 6A and 6C. Wall damage behind toilets in room 617 and 622. Damaged wall paper in 7E Soiled Utility Room. Paint in need of touching up in 805, Maternity Supply, Maternity Nourishment Room, and Triage. Wall damage in Maternity Nourishment Room. Loose wall Maternity molding in the Soiled Utility Room. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.4: Light bulb not working near the hand sink in ED Triage Waiting Room and above the shower in 5820. All areas shall have sufficient illumination. Maintain 10 foot candles of light at 30 inches above the floor in all areas other than food service areas. 15A NCAC 18A .1311 (a). 5: Ceiling fan blades collecting dust in room 820. Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). 10: Bed pans not labeled in 4C, 585. Bedpan with name only in 662. Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c). 13: No hot water in the CVI Waiting room. 75F in D784. 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).15: No vacuum breaker on shower wand in 3C Tub Room. Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).17: Water fountains with residue in ED Waiting Area. High pressure at the water fountain in 5A Hall. Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a).18: Disposable water pitcher not labeled in C470. Label all disposable water pitchers with the resident’s/patient’s first name and last name. 15A NCAC 18A .1314 (a).30: Dirty Pyxis machines in 6A, 6C, and 6F. Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).33: Soiled linen exposed and not labeled as such in PED ED X Ray. Soiled linen not labeled as such (bag inside out) in ED, and 7F. Soiled linen exposed in ACU and OR Soiled Utility Rooms. 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). 35: Provide approved disinfectant procedure to finger stretching device. Based on design of device, using wipes or sprays may not be effective. Patient contact items that become contaminated during use shall be cleaned and disinfected after each use. 15A NCAC 18A .1319 (c).42: Fruit not covered in the rolling food cart in 7F. All food while being stored, prepared, transported, displayed, and served, shall be protected from contamination. 15A NCAC 18A .1323 (a).General Comments: Recommend labeling urinals. Do not use single service foam cups as a funnel to fill up ice bags. Do not overstock supply bins in Resp. storage NICU. Empty trash often to prevent overflow. Do not store purses next to patient care items. Do not place rolling cart in front of hand sink (NICU).
#8 · Facilities conveniently located, clean and in good repair −1
Dirty shower head in H31. Slow sink drain in Adult ED room 3, 519, and 571. Low water pressure at sink in Adult ED Med Room. Soiled toilet and sink caulk damage in ED Care Station B restroom. Toilet with residue in Nuclear Med. Bathtub damaged and a rusting shower head in 652. Leaky at a spray arm in E905. Dirty sink in the 7E Group Room. Loose non-slips tub tape in E908. Sticky residue on the bathtub and a damaged toilet seat in PEDS 232. Keep all bathing equipment, sinks, and toilets clean and in good repair. 15A NCAC 18A .1312 (a),(b), and (f).
#12 · Lavatories have mixing faucet or tempered water, soap hand towel and hand drying device −1.5
Soap dispenser not working in 3C Med Room and in E908. No soap or paper towels in the 3 ICU Tub Room. No soap at the ED Care Station B Soiled Utility Room, Clean Utility Room ED Triage, and ED Triage Soiled Utility Room. No paper towels in the CVRU Soiled Utility and 5A Nourishment. Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d).
#19 · Ice protected, dispensed, equipment clean in good repair −1
Dirty ice chute in 3 Outpatient Infusion, CVRU Nourishment room, and Adult BH Nourishment room. Ice machine with mold on the water spout in ED Triage, PED ED. 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).
#28 · Adequate storage, area clean, items properly stored −0.5
Single service cups near sink edge in 3C Nourishment. Chemicals stored with paper products on housekeeping cart in ED Care Station B. Rusting wound care storage cart in ED Triage. IV bags at the sink edge in Clean Utility 5F. Toys stored in the Cath Lab Soiled Utility Room. Dirty storage bins in Sterile Core B. Dirty equipment left in hallways and “clean storage areas” in OR. Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Damaged bed handle in ED Triage Room 1. Tape residue on surfaces in the Phlebotomy Room ED Triage. Damaged chairs in ED Triage Hallway. Damaged waiting room cabinet handle in ED Triage. Damaged chairs in 6A 6C waiting area. Damaged closet in room E930. Soiled baby bed in PEDS 232. Laminate damage on furniture in 820. Stained couch pillows in 820. Monitors collecting dust in NICU. Bassinet railing damaged in NICU. All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
Clean beds made up and parked in units, with no sheet protecting the clean linen in ACU Hall , 5C and Dialysis. Clean linen exposed in ED Triage Room 1, ED Triage, 6F, and 6 EEG exam room. Chemicals stored above linen in PED ED room 10. Clean linen stored with misc items Diagnostic Room 1 and Ultra Sound Room 4. Damaged pillow linen in 6D 695. Clean blankets stored in the CVRU Soiled Utility Room. Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. 15A NCAC 18A .1319 (b).
#36 · Approved utensils and equipment, cleaned and sanitized −1
Melted items in 3C Nourishment freezer. Dirty food bins in Nourishment Room in ED Care Station C, and PED ED Nourishment. Burn marks in the 5C Nourishment microwave. Dirty shelving in 7F Nourishment and ACU Nourishment. Fridge gasket torn in PEDS 232. Countertop sticky and dirty in PEDS Nourishment. Fridge gaskets dirty in Maternity Nourishment. 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).
Nov 14, 2013 95 / 100 · 5 violations
Inspector comments: 1: Flooring damaged/floor drains and plumbing in need of capping in Hydrotherapy.Floors in intensive care units, bathrooms, showers, hydrotherapy areas, operating rooms, soiled utility rooms and laundry areas shall be of smooth, non-absorbent materials and so constructed as to be easy to clean. 15A NCAC 18A .1309 (a). 2: The drain line/floor drain collecting debris in 7ETC Nourishment.Keep all flooring clean. 15A NCAC 18A .1309 (a).3: Damaged hallways doors in Hospice. Wall damage and missing baseboards of Sterile Area of OR. Damaged wall beneath a counter in 7ETC day area of IM.Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.5: Vents collecting dust in 347. Rusted vent on the ceiling in 7ETC clean linen. Dusty vents in the day area and E929 of IMKeep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).9: Storage in a staff restroom in Neuro ICU.Toilet rooms shall not be used for storage. See rule .1312 (b). 13: Hot water at 86F in 6A and 6C Family waiting area. Hot water at 81.5F in room 610. 82F in room 620. 95.5F in Cardio Vascular Women’s restroom. 68F in Cardio Vascular stall Women’s restroom. 77.8F in room 513. Maintain the hot water at all resident accessible hand washing sinks and bathing facilities within the temperature range of 100°F to 116°F. 15A NCAC 18A .1312 (e).14: Per custodian: Disinfect not left on the surface long enough per instructions. 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). 15: No backflow prevention device on the shower wand in 816. Utility sink with no backflow prevention device in 3D Dialysis Work Room. Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).18: Disposable water pitcher not labeled in 7806. Only dated in 7ETC E913. Label all disposable water pitchers with the resident’s/patient’s first name and last name. 15A NCAC 18A .1314 (a).19: Ice machine collecting residue in 4C Med Room, 7F Nourishment, and 7NICU Nourishment.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: Dirty Pixis units in NICU Med Room and Chemo Med Room.Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).33: Soiled linen not fully bagged in ED A Soiled Utility and in PEDS Soiled Utility.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: A partially covered clean linen cart in 3D. A linen cart cover damaged in L and D Triage Storage. Clean linen placed on a bed that was stored in a hall in ED C. Spills/residue collecting on a clean linen cart in L and D Clean Utility.Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. 15A NCAC 18A .1319 (b).35: A damaged vinyl pad in Radiology 1. A pad collecting tacky residue in NICU. Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).40: Food not labeled properly in 5C Nourishment and ED C Nourishment. 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).Remove "Soiled Utility" Placard off of the EVS door in Endo Prep/Recovery area. Use the actual Soiled Utility Room. If the EVS room is used as Soiled Utility then a hand sink must be installed.
#8 · Facilities conveniently located, clean and in good repair −1
Observed: Slow draining sinks in 536, 513, and 575. A slow tub drain and a shower curtain collecting residue in 7D. Shower head collecting residue in 347. Shower curtain collecting residue in 7D 784 and in 7ETC 914. Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Keep all hand washing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
#12 · Lavatories have mixing faucet or tempered water, soap hand towel and hand drying device −1.5
Observed: No paper towels at CCU Soiled Utility and OR side A Soiled Utility. Soap dispenser not working in 4C Clean Utility. Soap dispenser not working in Women’s Health Clean Utility, Women’s Health Aux Med Room, L and D Soiled Utility and L and D Ante Room. Provide liquid soap and disposable towels at all hand washing sinks. 15A NCAC 18A .1312 (d).
#28 · Adequate storage, area clean, items properly stored −0.5
Observed: Storage within 8” of the floor in CT storage near PET. Toilet paper being stored in ED B Soiled Utility. Items stored within the splash zone in 5A Med Room. Pill crusher stored in the splash zone in 3D Med Room. Towels stored next to sink in 382. Single service cup dispenser with no lid in the Nourishment room on 8th floor. Single service cups stacked too high 7C Nourishment. Pill cups at Nurse Stations stored in a dirty container in Aux Med Room of Women’s Health and not protected/inverted on a shelf in Women’s Health. Dirty/broken shelving and drawers in Women’s Health Supply Room and L and D Triage 1. Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a).All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed: A phone collecting residue in 575. Couch laminate damaged in Hospice. Rusted bed frames in 347, 380, 382, and 465. Debris collecting beneath chair pillows in 3D Family Room. Cracked bassinette in 8th floor Clean Equipment Room and Nursery. Incubation bed with a torn mattress in 8th floor Storage. Residue beneath the bench in 7813. Damaged furniture in 7ETC day area IM and in 7ETC 929. Rusted bad frame and loose paint in 7ETC Restraint Room. Mattress damaged in 7ETC Seclusion Room. Single service cups left uncovered in 7ETC Day area IM. Residue collecting on room curtain in 7ETC 929. All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, Venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
#36 · Approved utensils and equipment, cleaned and sanitized −1
Observed: Cabinets wet and bins dirty in ED C Nourishment. Microwave, oven, cabinets, and coffee maker collecting debris and residue in Hospice. Microwave collecting residue in 4C Nourishment. Fridge shelving, cabinets, and coffee maker collecting residue in 6F Nourishment. Residue collecting in the cabinet, beneath the coffee maker, in 7ETC Nourishment day area. Fridge gaskets damaged 7F Nourishment and NICU Nourishment. Sticky drawers in L and D Nourishment. Microwaves collecting residue in Neuro Nourishment, 5C Nourishment. Freezer needing defrosting in 5C Nourishment and 5F Point of Care.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).Inspection assisted by: Stephen Graham, Tasharra Kenion, Chris Sells, Nykesse Roberts, and Nicole Bruce.
Nov 14, 2013 no score published · 0 violations
Inspector comments: 36:Observed: Cabinets wet and bins dirty in ED C Nourishment. Microwave, oven, cabinets, and coffee maker collecting debris andresidue in Hospice. Microwave collecting residue in 4C Nourishment. Fridge shelving, cabinets, and coffee maker collecting residuein 6F Nourishment. Residue collecting in the cabinet, beneath the coffee maker, in 7ETC Nourishment day area. Fridge gasketsdamaged 7F Nourishment and NICU Nourishment. Sticky drawers in L and D Nourishment. Microwaves collecting residue in NeuroNourishment, 5C Nourishment. Freezer needing defrosting in 5C Nourishment and 5F Point of Care.Non-food contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. Seerule .1320 (c).
No violations were recorded for this inspection.
Source: Mecklenburg County Public Health – Environmental Health public inspection portal (search for “NOVANT HEALTH PRESBYTERIAN MEDICAL CENTER” or State ID 2060410009). Inspection type (routine vs. follow-up) is not published in the county's data.