98/ 100
ATRIUM HEALTH UNIVERSITY CITY
8800 N TRYON ST, Charlotte, NC 28262
Hospitals · NC permit/State ID 2060410014
Latest result98 / 100
Last inspectedJun 9, 2026
Inspections on record23
On record sinceOct 9, 2013
Score history
Oct 9, 2013Higher is betterJun 9, 2026
Inspections & violations
Jun 9, 2026 98 / 100 · 1 violation
Inspector comments: NOTE:
- EHS: Ponpasert, Natalie and the Hospital Administrative Team were present during inspection.
#7 · Facilities provided, accessible, clean, good repair −2
REPEAT
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair.- Observed crack in toilet bowl in room 17 labor/delivery. Observed slow drain at hand sink in OR, Pre op restroom, restroom sink in ER, dressing room in radiation, and Room L133 in radiation. Observed soiled sink in radiology, soiled hopper in PACU, damaged toilet seats need replacement in public restroom in ER. Repair/replace/keep all facilities clean.
Sep 17, 2025 99 / 100 · 1 violation
Inspector comments: NOTE:
EHS: Ponpasert, Natalie and the Hospital Administrative Team were present during inspection.
#7 · Facilities provided, accessible, clean, good repair −1
REPEAT
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair.- Observed slow draining at hand sinks in ED OBS area, mildew around faucet at hand sink in women restroom Pre-Op waiting area. Damage/stain toilet seat in woman restroom in lobby area. Point remain the same due to major improvement.
May 28, 2025 98.5 / 100 · 3 violations
Inspector comments: NOTE:
EHS: Ponpasert, Natalie and Hospital administrative team present during inspection.
#7 · Facilities provided, accessible, clean, good repair −1
REPEAT
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair.- Observed slow draining at hand sink (restroom endoscopy, Endo observation room, nurse station ED,
Patient room 16, and restroom next to room 31/30 in ED). Observed soiled hopper in soiled room in 03T112. Repairing/cleaning needed. Keep clean and good repair. Half point due to improvement.
#38 · Food service equipment and utensils clean, good repair −0.5
REPEAT
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair.- Observed water damaged cabinets in 3rd floor nourishment room 03T120. Repair/replace needed. Half point due to improvement.
#43 · Food brought into the institution by employees or visitors of patients or residents properly stored, labeled and dated
General Comment:
.1321 (b) Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply as described in rule .1321 (a). Such food shall be labeled with the name of the resident or employee that the food belongs to and the date the food was brought into the institution. Labeling as required by this Rule shall not be required for food items stored in employee-designated or individual residents' refrigerators or rooms.- Observed a cup of Starbucks coffee stored inside food/snack cabinet AD, mixing with patient snacks provide by facility. Observed food brought in by a family member according to staff stored in nutrition room- 4th floor dated 4/22. Ensure to store food (employees or patients) appropriately and date marking up to 7 days for food safety.
Nov 13, 2024 97 / 100 · 4 violations
Inspector comments: NOTE:
EHS: Ponpasert and Natalie, Hospital administrators staff: Joseph and the whole team present during inspection.
#2 · Walls and ceilings clean, good repair
General Comment:
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. Observed stained ceiling tile in room 25 of maternity. Check for leaks, repair/replace ceiling tile.
#7 · Facilities provided, accessible, clean, good repair −2
REPEAT
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair.- Observed soiled or black mildew stain in toilet bowl patient restroom endoscopy. Observed pink buildup around the drain in hand sink in Imaging. Observed pink build up around drain in maternity 25 and pink build up around jets in maternity 0. Detail cleaning needed and keeping cleaned.
.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 disposable urinal missing label in room 415. Needs label.
#10 · Handwashing facilities properly located and equipped
General Comment:
.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices.- Observed no paper towels available due to dead batteries on the dispenser, hand sink in clean utility LCI. Ensure to have all hand washing supplies available at all time at all hand sinks.
#38 · Food service equipment and utensils clean, good repair −1
REPEAT
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair.- Observed in ED nourishment room, soiled microwave (ceiling), drawers/cabinets need detail cleaning and keeping clean. Observed water damaged cabinets in 6th floor and 3rd floor nourishment rooms. Repair/replace needed.
Jun 25, 2024 98 / 100 · 3 violations
Inspector comments: NOTE:
EHS: Natalie and Ponpasert, Hospital staff: Bill, Stephanie, Kint, Alan present during the inspection.
#7 · Facilities provided, accessible, clean, good repair −1
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair.- Observed blocked hand sink in soiled room in endoscopy and hand sink blocked by trash cans in 03T112 soiled utility. Observed black mildew stain in toilet bowl endoscopy restroom hallway. Observed slow draining at the hand sink in radiology restroom.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair −0.5
REPEAT
.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair.- Observed damaged at corners of blue mattress in ED. Observed torn chair in room 500. Point remain the same.
#38 · Food service equipment and utensils clean, good repair −0.5
REPEAT
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair.- Observed in ED nourishment room, soiled microwave, refrigerator, and drawers/cabinets need detail cleaning and keep clean. Observed microwave, refrigerator, water dispenser, and counter under coffee maker in need of cleaning in Nourishment 03T120. Observed cabinet in need of cleaning in Nourishment on floor 6.
Dec 1, 2023 98 / 100 · 5 violations
#10 · Handwashing facilities properly located and equipped
.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices.- Observed hand washing sink in the lab without soap. Provide all hand washing supplies at all hand sink at all time.
#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 water temperature in the operating room ranged from 71F-74F in most of the hand washing sinks. In the recovery room water temperature ranged from 81F-98F. Provide tempered water between 105F to 116F.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair −0.5
.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair. -Observed damaged/start to fray navy blue mattresses in ER department and one severe damaged in radiology room. Observed damaged leather chair in room 506, peeling laminate on cabinets and drawers in room 18 on maternity floor. Need repair or replacement.
#38 · Food service equipment and utensils clean, good repair
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair.- Observed soiled microwave need to be cleaned in ER and rusted microwave need replacement in the lab.
#45 · Hot and cold holding equipment provided; thermometers provided, accurate
.1323 (b) Hot and cold holding equipment shall be used to maintain the required temperatures for TCS food. Each refrigeration unit shall be provided with an indicating thermometer that is accurate to ±3 degrees Fahrenheit or ±1.5 degrees Celsius.- Observed malfunctioning thermometer indicating temperature at 67F in ER nourishment room refrigerator. The ham sandwich in the refrigerator temperature measured at 41F. Obtain a new working indicating thermometer.
Jan 18, 2023 98.5 / 100 · 8 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. Continue to wipe scuff marks from lower section of wall in lobby, hallway area and anywhere else needed. Replace cracked/damaged corner wall guard. General Commented
#9 · Bedpans, urinals, bedside commodes and emesis basins properly cleaned and disinfected
.1312 (c) When disposable bedpans, emesis basins, and urinals are reused, they shall be labeled so that they are associated with an individual resident. Observed (1) emesis basin not labeled identifying emesis basin to patient in the room. General Comment
#31 · Feeding bags, tubes, syringes and oral suction catheters properly handled −1
.1318 (b) Feeding bags, tubes, syringes, and oral suction catheters shall be stored and used in accordance with the manufacturer's instructions. Observed boxes of items stored on the floor. Store items on shelving.
#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 chairs in ED worn and damaged. Informed by hospital administrators that furniture has been ordered to replaced damage and worn chairs in ED. Wipe/dust base of computer on wheels (cows) used on different floors. Touch-up old wooden head board with furniture marker used in maternity triage.
#33 · Bed linens in good repair; soiled linens changed, properly handled, containers properly labeled −0.5
.1319 (b) A resident's bed linens shall be changed when no longer clean. Observed (1) soiled linen on isolette (baby warmer). Replace stained linen. Observed clean linen on beds in the public hallway area on different floors. Store a sheet over made beds being stored or placed in the hallway area.
#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. THE NEW COLD HOLDING FOR FOOD PRODUCTS IS 41F. Recommend turning down temperatures on refrigeration units to ensure food products are being held at 41F and below.
#51 · Proper use of restriction, exclusion, and reporting
.1324 (c) Institution employees shall comply with the requirements for exclusion from work and restriction due to communicable disease or illness required for food employees as set forth in Parts 2-201.12 and 2-201.13 of the Food Code incorporated by reference at 15A NCAC 18A .2650 as amended by 15A NCAC 18A .2652. Will send administrators the employee health policy.
#52 · Vomitus and diarrheal clean up supplies; written clean up procedures available and complete
.1324 (d) The institution shall have gloves, personal protective equipment, disinfectant, individual disposable towels, and a coagulating agent on-site for employees to use and a written procedure for employees to follow when responding to vomitus or fecal matter on institution surfaces. The procedure shall specify the actions that employees shall take to minimize the exposure of employees, residents, guests, food, and additional surfaces to vomitus or fecal matter. Provide a vomitus's and diarrhea clean up plan and supplies. Will send administrators vomitus and diarrhea clean up plan procedure.
Sep 26, 2022 98 / 100 · 1 violation
Inspector comments: #3. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Continue to secure loose corner of wall paper throughout where needed; if needed (area near handwashing sinks and at bends on walls). Tightly secure loose corner wall protectors. Repair hole in wall in room 604 and continue to patch small holes in walls throughout where needed. Monitor ceiling around column in waiting area and repair if needed. Wipe/dust high window ledges.
#8. 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)Observed base corner of shower soiled in (1) room, EVS called immediately to clean and disinfect base corner of shower. Observed (1) faucet fixture on hand washing bin/trough in maternity operating room not working. Maintenance came immediately and repair faucet fixture on hand washing sink. Hand washing sink/bin/ trough consist of two faucet fixture, which (1) was not operating, but repaired at time of inspection.
#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). Continue to refurbish or replace nightstands/bedside tables in rooms and wooden head board in maternity units. Refurbish or replace chairs in waiting rooms which covering is damaged/ torn/worn. Wipe/dust top of fixtures/furniture.
#39 · Food supply complies with 15A NCAC 18A .2600 −2
All food and food supplies provided by an institution shall be from sources that comply with 15A NCAC 18A. 2600. Observed (TCS foods) in nourishment refrigeration unit on the sixth floor with a discard date of 9/23, 9/24 and 9/25 date. Make sure food products are pulled and discarded from nourishment refrigeration unit in a timely manner not to extend past the discard date by nursing or food service staff. Todays date is 9/26/2022.
Mar 11, 2022 99 / 100 · 1 violation
Inspector comments: #3. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
Continue to touch-up paint throughout in rooms and storage rooms. Tightly secure loose corners/edges of wall paper throughout where needed. Re-stain/refurbish doors to rooms.
#8. Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
Observed broken shower wands holder broken on several showers throughout in rooms. Replace broken shower wand holder in bathroom/showers within rooms.
#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). Continue to refurbish bedside stands and chairs where varnish is wearing and worn from wooden part of furniture/fixtures or replace.
#33. Soiled linen shall be placed in a covered container or bag at the point of use and stored and handled so as to contain and minimize aerosolization of and exposure to any waste products. 15A NCAC 18A .1319 (b). Observed open lid on (1)soiled linen bin in biohazard room. Soiled linen bin lid closed at time of inspection.
#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −1
Observed boxes of patient contact items stored on the floor in 6th floor storage room. Observed employees personal belongings (purse and food) stored above dialysis supplies in dialysis storage room. Store employees personal belongings in designated area, not near hospital supplies. Store patient contact items on shelving, dunnage rack, transfer cart, etc.; not on the floor.
Aug 17, 2021 99 / 100 · 1 violation
Inspector comments: #3. Continue to touch-up paint door framing throughout where needed.
#32. Continue to touch-up furniture (night stand) within rooms, throughout where needed; if needed.
#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −1
Observed boxes of patient contact items stored on the floor in clean supply room on 6th floor. No storage on the floor. Provide additional shelving in clean supply room if needed. Store items at least 8 inches off the floor.
Dec 3, 2020 99 / 100 · 2 violations
Inspector comments: General Comment:
#3.Repair loose/damaged wall paper in ICU6. Tightly secure loose rubber cove base moulding in 1 room underneath plumbing clean out.
#32. Continue to replace worn furniture throughout (night stand and furniture used in the maternity ward). Touch-up furniture with a furniture marker where needed.
#28 · Adequate storage, area clean, items properly stored −0.5
Observed IV storage under paper towel/soap dispenser and near hand washing sink in a room in ER. Move clean storage shelving away from hand washing sink in special care nursery to prevent contamination of clean items. Store patient care items and consumable items in a manner to prevent contamination.
#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −0.5
Observed clean linen bin uncovered in storage room which is also used for general storage. Keep clean linen bin covered when linen is store with general storage. Observed clean linen placed on stretchers throughout the ER in the hallway area. Cover stretcher in ER with a cover sheet since the ER is a high traffic area and to prevent the contamination of cleaan linen on stretchers stored in the ER.
15A NCAC 18A. 1319 Patient contact items storage
Dec 12, 2019 97.5 / 100 · 3 violations
Inspector comments: NO POINTS DEDUCTED
#21
Maintain dumster areas; good repair and clean. Observed rusty areas of compactor in need of repair; Observed standing sludge material collected around compactor area in need of removal.
#32
Maintain furnishings in good repair; Observed worn (fetal monitor) carts in rooms on Maternity floor.
#33
Maintain linen clean and in good repair; Observed small stain on bed mat inside room #18 on Maternity floor.
Labeled soiled linen containers; Observed soiled linen containers not labeled throughout.
#3 · Walls and ceilings cleanable, clean, good repair −1
REPEAT
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed scuffed walls / damaged wall boarders in rooms (clean supply, #18) on Maternity in need of touch-up painting; Observed wall damaged / scuffed in clean supply room on 3rd floor in need of touch-up painting / repair. Observed walls (corners / base boards) in ICU / clean utility 6th floor in need of repair.
(POINTS NOT INCREASED DUE TO IMPROVEMENT)
#13 · Lavatory and bathing hot water between 100 and 116 F −1
Maintain the hot water at all resident accessible handwashing sinks and bathing facilities within the temperature range of 100°F to 116°F. 15A NCAC 18A .1312 (e). Observed hand washing sinks installed with auto-run sensors not reaching 100F (97F) inside OR areas.
#28 · Adequate storage, area clean, items properly stored −0.5
Patient care or consumable items and /or supples shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a). Observed misc storage under hand washing sinks inside CT room.
Jun 26, 2019 98 / 100 · 2 violations
#3 · Walls and ceilings cleanable, clean, good repair −1
REPEAT
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed wall damage inside mens locker room (PACU); Observed wall inside Female locker room in need of repair (near loading dock area); Observed large section of damaged wall inside (clean processing) in need of repair. Observed wet paper towels thrown on ceiling inside womens restroom in (ER) lobby.
#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 misc supplies, food, debris collected underneath bottom drawers at nourishment areas; Observed rusty bed frame in room #8 (ER) in need of repair.
Dec 4, 2018 96 / 100 · 4 violations
Inspector comments: NO POINTS DEDUCTED
#12
Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). No soap at both hand sinks in Lab.
#3 · Walls and ceilings cleanable, clean, good repair −1
REPEAT
Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed walls scuffed in majority of storage / supply rooms in need of touch-up painting on all floors; Observed walls scuffed in patient room #613 in need of touch-up painting.
(POINTS NOT INCREASED DUE TO IMPROVEMENT)
#8 · Facilities conveniently located, clean and in good repair −1
REPEAT
Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b) Slow drain in Radiation Therapy; hand sink area soiled in the LAB and Hopper in OR need of general cleaning.
Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed toilet paper dispenser broken in need of repair.
(POINTS NOT INCREASED DUE TO IMPROVEMENT)
#34 · Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately −1
REPEAT
Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. 15A NCAC 18A .1319 (b). Clean Linen on beds in hallway with only one sheet on beds; Both OR and Endo.
(POINTS NOT INCREASED DUE TO IMPROVEMENT)
#36 · Approved utensils and equipment, cleaned and sanitized −1
All kitchenware and food contact surfaces of equipment, exclusive or cooking surfaces of equipment, used in preparation or serving of food or drink, and all food storage utensils, shall be cleaned after each use. 15A NCAC 18A .1320 (c).
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).
Microwave ED and cabinet interiors in need of cleaning in Nourishment rooms in Endo and ED.
Cabinetry in need of cleaning at coffee station in Maternity.
May 9, 2018 96 / 100 · 4 violations
Inspector comments: NO POINTS WERE TAKEN FOR THE FOLLOWING:
#2 - Observed tile grout in need of cleaning in restroom of 5th floor waiting room. **Keep all flooring clean. 15A NCAC 18A .1309 (a).
#18 - Observed water pitcher without label in 316. **Label all disposable water pitchers with the resident’s/patient’s first name and last name. 15A NCAC 18A .1314 (a).
#36 - Observed roof of microwave in need of cleaning in nourishment room of ER, maternity, and 6th floor. Observed heavily soiled refrigerators in patient refrigerators in clean supply in ER, LDRP, and 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).
#40 - Observed one employee lunch being stored in the patient refrigerator in ER clean supply room without labeling. **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).
#3 · Walls and ceilings cleanable, clean, good repair −1
REPEAT Observed wall damage throughout in storage rooms, hallways, and room 308. Observed wall splatter in PACU bay 9 and 3rd floor telemetry storage closet. Observed touch-up paint needed in bay 9 PACU.
**Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#8 · Facilities conveniently located, clean and in good repair −1
REPEAT Observed shower head with build-up in 542 and 607. Observed shower tile grout in need of cleaning in restroom of 542, 515, 308, and 316. Points not escalated due to improvement seen in majority of areas.
**Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
REPEAT Observed mattresses in ER rooms 4 and 5 with tape residue collecting debris. Observed worn chair in 625.
**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
REPEAT Observed soiled linen bags with clean linen stored in them and soiled linen bags being stored with clean linen throughout. Observed miscellaneous items being stored in cabinet with clean linen in CT scan room 1. Observed paper made up into sheets in PACU bay 1 bed. Observed chemical wipes and other items being stored in same cabinet with clean linen in maternity.
**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).
Dec 28, 2017 96 / 100 · 3 violations
Inspector comments: NO POINTS WERE TAKEN FOR THE FOLLOWING:
#2 - Observed cleaning needed in the grout of family bathroom on third floor Telemetry. **Keep all flooring clean. 15A NCAC 18A .1309 (a).
#3 - Observed damaged laminate wall in closet of room 308. Observed wall damage in storage closet on third floor. Observed minor wall damage in the soiled utility room of 5th floor. **Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
#11 - Observed ice in hand sink of nourishment room on 5th floor. Ensure hand sinks are used for hand washing only. **Except for the stipulations stated in rule .1312 (d), hand washing sinks shall only be used for hand washing. 15A NCAC 18A .1312 (d).
#13 - Observed hot water reach 117F in room 533. **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).
#28 - Observed single-use cuffs being stored on floor in 5th floor storage room. **All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
#33 - Observed stained linen in one NICU pod. Observed sheets with sticky residue in room 532. **Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).
#34 - Observed linen wash cloths being stored in a drawer with other patient contact items in room 10 of PACU. **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).
#39 - Observed coffee accompaniments being stored below bulk supply of hand sanitizer in 5th floor storage room. **All food and food supplies shall be clean, free from spoilage, free from adulteration and misbranding, and safe for human consumption. 15A NCAC 18A .1321 (a).
Inspection completed by Alexandra Hall and Savannah Parker.
#8 · Facilities conveniently located, clean and in good repair −1
REPEAT Observed hopper in ED soiled utility with build-up in need of cleaning. Observed grout missing between tiles shower floor in room 308. Observed hand sinks obstructed in the storage rooms on 5th floor. **Toilet, hand washing, and bathing facilities must be conveniently located and readily accessible to residents and staff. 15A NCAC 18A .1312 (a).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
REPEAT Observed rips mattresses in room 10 of PACU and on 2nd floor hallway. Observed chair with residue in family room on fifth floor. Observed stained pillow in ICU5.
**All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
#42 · Food protected. Potentially hazardous food maintained at 45 F or below, or 140 F for above, consumed or discarded within 2 hours of being removed from temperature control −2
REPEAT Observed items such as turkey sandwiches and milk being stored above 45F in 3rd floor nourishment room refrigerator.
**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).
May 30, 2017 96.5 / 100 · 4 violations
Inspector comments: General Comment: No points
#3: Observed stained ceiling tiles housekeeping area 2nd floor. Peeling paint door jambs in ED. Rm. 616 closet wall damaged. **Keep walls and ceiling clean and in good repair.
#43: Observed maternity #1 and #19 refrigerators were turned off for defrosting and not turned back on. **TCS food shall maintain 45F or below.
#42: Observed milk at 51.5F in 5th floor nourishment room, Keep TCS food 45F or below during transport.
#8 · Facilities conveniently located, clean and in good repair −1
Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b) Observed slow drains in Endoscopy hallway sink and ED nourishment room. Trash in trauma room. Utensils in hand sink of ED nourishment room.
Rusted fixture base of hand sink ED nurse's station. Rm. 616 shower curtain with residue and debris. Maternity rooms #1 and #19 shower grout with residue.
Toilet, handwashing, and bathing facilities must be conveniently located and readily accessible to residents and staff. 15A NCAC 18A .1312 (a). Observed blocked hand sinks in ED nourishment room and ED overflow
#28 · Adequate storage, area clean, items properly stored −0.5
All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). Observed storage less than 8 inches above floor in main OR supply room. 6th floor clean utility chemicals stored above clean supplies.
#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 an unwrapped needle . . on bedside table of ED #15. Torn pillow in ED #15. Torn mattress in ED hallway. Rm. 605 and 616 chair seams with residue. Waiting room chairs with trash under cushions, 1st floor. Cabinet damaged at refrigerator, maternity room #1.
#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 microwaves with residue on 1st floor, 5th floor and 3rd floor. Microwave rusted on 6th floor nourishment. 6th floor and 1st floor nourishment refrigerators need cleaning.
Nov 14, 2016 98.5 / 100 · 2 violations
Inspector comments: No Points Deducted: 8. Handwashing sinks blocked in some areas. Keep all sinks accessible. Shower curtains with residue and slow draining sink in R22. Shower floor not cleanable in R318. Keep all handwashing and bathing equipment clean and in good repair. #11. Observed paint brushes being cleaned in a handwashing sink. Only use handwashing sinks to wash hands. 18. Observed water pitchers not labeled in R22 and R318. Label all water pitchers with the patients name. 17. Observed water fountains with high pressure in waiting areas. Observed water fountains on the 6 and 5 tower floor waiting rooms with white residue. Keep all water fountains clean and in good repair. 36. Observed a refrigerator with residue and a burnt microwave in R26. 21. Observed the dumpster area collecting debris. Keep the dumpster area clean.
#28 · Adequate storage, area clean, items properly stored −0.5
Observed the following: Clean items stored under a sewage line and cabinets collecting residue in the 6th floor nourishment room. Chemicals stored above clean items on the 6th floor. Food stored with misc. items and storage on the floor on 3T. 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). 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 the following: Rusty bed frames in rooms 503, 616, and 506. Couch collecting debris in 3T consult room. Laminate damaged at refrigerator cabinet and seat crevices with residue in room 26 maternity. Damaged mattresses in ED hallway, ED Room 29 and Cardiac Cath Patient Holding 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).
Apr 15, 2016 98 / 100 · 3 violations
Inspector comments: 1.Observed damaged base tile cove moulding in decontamination room in ED area. Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b).
8. Observed some build-up in base corner of shower in room on 3rd med tele. Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).
17. Observed build-up in water nozzle on water fountain in PACU Pre Op. Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a).
30. Observed dust in base of omni cell. Clean/dust base of omni cells. Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).
31. Observed plunger and feeding tube syringe stored on paper towel on over bed table in ICU. Recommend storing plunger and feed tube syringe in a plastic container.
Feeding syringes and oral suction catheters shall be stored in a clean container. 15A NCAC 18A .1318 (d).
34. Observed linen closet door opened in exam room 34 in the ED area. Keep door closed on linen closet/ cabinet within exam rooms. 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.Clean freezer shelf on 6th floor. 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).
40. Observed patient food products from outside source stored in locked nourishment room with date and patient room number. Label outside food products with date and resident name! Food product properly labeled at time of inspection. 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).
43. Provide thermometer in maternity refrigeration unit. All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b).
#28 · Adequate storage, area clean, items properly stored −0.5
Observed Styrofoam cups not properly stored and needle/ equipment caps stored on pillow in Cath Lab. Observed bottle of hand sanitizer stored on the floor in CT Control room. Observed forensic paper stored on the floor in exam room 27 in ED. Observed clean supply in sterile package stored on top of bio hazard/sharps container in Endoscopy. DO NOT STORE OR PLACE CLEAN/STERILE SUPPLIES ON TOP OF BIOHAZARD/ SHARPS CONTAINER!
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).
#33 · Linen changed when soiled. Soiled linen handled properly −1
Observed soiled linen bins not properly labeled within soiled utility rooms. Label soiled linen bins. Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b).
#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −0.5
Observed damaged liner in boot used in CT Control Room. Replace damaged boot. Observed damaged arm rest on wheel chairs used in ED. Replace damaged arm rest on sheet chairs or replace wheel chairs. Observed damaged body position and old tape adhesive on body position in Radiology. Observed torn sheet in NICU. Replace torn/damaged sheet.
Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).
Dec 22, 2015 96.5 / 100 · 4 violations
Inspector comments: 2. Observed can wash basin collecting residue in cath lab environmental closet. Observed blood on floor in exam room 33 in ED.Keep all flooring clean. 15A NCAC 18A .1309 (a).3. Observed wall damage in radiology storage, room 309, and cath lab environmental closet. Observed water stained ceiling tile over omnicell in endo hallway, and in MRI hallway next to CT Scan 1. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.15. Observed shower wands throughout third floor with no backflow prevention device.Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).17. Observed low pressure on water fountains in maternity wattling room.Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a).30. Observed omnicell with dust present at bottom, and medication refrigerators collecting debris/residue.Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).33. Observed sheet with tape present on backside in room 540. Observed uncovered bed in hallway in radiology.Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).39. Observed refrigerator with patent food dated august and October inAll food and food supplies provided by an institution shall be from sources that comply with 15A NCAC 18A. 2600.
#8 · Facilities conveniently located, clean and in good repair −1
Repeat non-compliance: Observed rust stains in 302 and 309. Observed leaking faucet in ED Decontamination. Observed dirty shower curtain and shower chairs in Maternity 26.Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)Improvement from previous inspection.
#28 · Adequate storage, area clean, items properly stored −0.5
Observed trays stored on hopper in Endo soiled utility. Observed boxes of pillows stored on floor in ED supply 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).
#31 · Feeding syringes and oral suction catheters handled properly, tube-feeding bags changed per instructions −1
Observed feeding syringe stored together in water in graduated cylinder in 6th floor ICU 1.Feeding syringes which are reused shall be labeled with the patient's name and date opened, shall be disassembled and rinsed after each use, and shall be disposed of within 24 hours of first use. 15A NCAC 18A .1318 (d).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Repeat non-compliance: Observed one damaged chair in 309. Observed tape residue on mattress in cath lab bay and torn mattress in cath lab bay. Observed damaged mattress and boot cover on stirrups in maternity 26, Observed damaged shelf in maternity room 26. Observed dust collecting in 5th floor linen storage in hallway. 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). Improvement from previous inspection.
May 14, 2015 97.5 / 100 · 3 violations
Inspector comments: #3 Observed slight wall damage behind door of Maternity recovery house keeping closet. #5 Observed dust debris build up on A/C vent in Radio room #2, ICU #6, 3rd floor hall next to OR recovery. Keep ventilation equipment clean and in good repair. #12 Observed paper towels not present at Endo hand washing sink. Paper towels shall be provided at all hand washing sinks.#13 Observed water temperature at 87F in OR Maternity hand washing sink. Water temperature shall meet 100 - 116F#36 Observed refrigerator bottom dirty in Maternity Storage room next to OR. Utensils and equipment shall be kept clean.#33 Observed stain on pillow case in Radiology #4 and Pre Op #6. Keep linen in clean.
#8 · Facilities conveniently located, clean and in good repair −1
Observed chair storage in Rehab 5 restroom. Observed damaged floor drain in 304, 316. Observed worn drain in 3rd floor nourishment room. Observed calcium build up in Emergency Department patient room #12. Staff stated incorrect hand hygiene procedure for hand washing at 6th floor processing of CPAP machines. Staff stated hands would be washed on clean side processing sink. Hand sanitizer must be used in this area in lieu of hand washing. **Keep all hand washing facilities clean and in good repair. 15A NCAC 18A .1312 (b)**Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).Facilities in operation prior to March 1, 2003 that do not have hand washing lavatories in all areas required shall have an approved hand hygiene program established. 15A NCAC 18A .1312 (d).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Repeat Non Compliance: Observed rip and or sticky tape residue present in MRI holding, triage #4, Maternity room #2, and nursery.Observed torn linen in ICU #6 and chest rolls ripped in Endo storage.**All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
#35 · Patient contact items in good repair, properly stored, cleaned and disinfected −0.5
Observed circumcision board collecting residue on underside. Store clean in circumcision room. Observed dirty pill crusher in 3rd, 5th floor med rooms.**Patient contact items that become contaminated during use shall be cleaned and disinfected after each use. 15A NCAC 18A .1319 (c).
Aug 27, 2014 98 / 100 · 2 violations
Inspector comments: 3. Observed wall damage in room 605 & 500. **Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.8. Observed calcium build up present on shower head in room 605, with pink residue on shower curtain seams in LDRP room 5 & 6 & 9. Observed LDRP, OR, Soiled utility room hand sink blocked and labeled "not for hand washing".**Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).**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).9. Observed chairs stored in toilet room 5th floor respiratory room. **Toilet rooms shall not be used for storage. See rule .1312 (b). 15. Continue installing back flow prevention devices on shower wands 4th floor. **Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d). 28. Observed clean urinals stored less than 8". **All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).36. Observed spilled coffee grounds in cabinet found in LDRP room 6. Observed freezer interior dirty in LDRP OR Clean Supply. **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).
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed debris, crumbs collecting below sofa cushion, chair in LDRP room 6. Observed damaged vinyl pad on baby bed in nursery, vynil pads collecting sticker tape on surface throughout 1st floor. **All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
#33 · Linen changed when soiled. Soiled linen handled properly −1
Observed several soiled utility carts throughout facility not properly labeled. **Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b).
Oct 9, 2013 97 / 100 · 3 violations
Inspector comments: 2: Clean floors in Radiology Soiled Utility. 3: Wall paper damage in restrooms and hallways on ground floor. Repair. Continue repairing walls from old dispensers. 8: Broken shower head in 513. Replace. Stains below hand sinks in ED common area and Endo. Clean. 12: Provide paper towels at the sink in 3T storage room. 15: Provide shower backflow prevention device in Maternity 2.Inspection assisted by Matthew Cook.
#32 · Furniture clean and in good repair. Mattresses clean, dry, odor free −1
Observed: Gum below a mattress in Radiology Overflow. Tape residue on a mattress in ED 27. Damaged slider doors in Maternity 5. All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
#33 · Linen changed when soiled. Soiled linen handled properly −1
Observed: Bags of soiled linen not closed shut in soiled linen carts. Other carts with soiled linen not contained in bags. Soiled linen shall be placed in a covered container or bag at the point of use and stored and handled so as to contain and minimize aerosolization of and exposure to any waste products. 15A NCAC 18A .1319 (b).
#36 · Approved utensils and equipment, cleaned and sanitized −1
Observed: Debris and crumbs collecting in drawers/cabinets in 6T Nourishment, 4T Nourishment, Maternity N Nourishment, and ED Storage/Nourishment Room. A damaged fridge gasket in 6T Med Room. A damaged fridge handle and dirty coffee maker in ED Storage/Nourishment.
Source: Mecklenburg County Public Health – Environmental Health public inspection portal (search for “ATRIUM HEALTH UNIVERSITY CITY” or State ID 2060410014). Inspection type (routine vs. follow-up) is not published in the county's data.