Premises Information


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Name

CUTHBERTSON VILLAGE

Address

3200 BISHOPS WAY LN

City/State/ZIP

CHARLOTTE

28215

Premise Type

40 - Rest/Nursing Homes

County

Mecklenburg

Inspection Date

2/27/2018

Final Score @ Grade

General Comments

No points taken: 16. The local health department shall be immediately notified if the primary water supply is interrupted for more than four hours. Each institution shall have a plan to obtain a backup water supply in the event that the water supply is lost for more than four hours. The backup water supply plan shall provide for two liters of water per day per person for drinking. The backup water supply plan shall include a plan for either relocating residents or providing an alternative source of water for essential functions such as food preparation, hand washing, bathing, cleaning, dishwashing, laundry and disposal of bodily waste. The amount of water provided for uses other than drinking may be reduced if the plan includes alternatives for water use for services such as laundry and dishwashing. If an assessment determines that tap water is not to be used for drinking, sources shall be prominently labeled or hooded to restrict use and potable water shall be provided. 15A NCAC 18A .1313(f) Observed backup water supply plan without details of amount of water that will be delivered. 28. Adequate storage, area clean, items properly stored. 15A NCAC 18A .1318(a) Observed depends stored under the sink in the bathroom less than 8 inches off the floor in room 9 and 23. 30. Medication carts clean, sharp containers affixed, food and utensils handled properly. 15A NCAC 18A .1318(c) Observed medication carts on A hall with some debris in front of the narc box. Observed 2 medication carts in A hall that had bleach wipes and disinfectant spray stored with tissues and single service cups that were in plastic bag. 32. Furniture clean and in good repair. Mattresses clean, dry, and odor free. 15A NCAC 18A .1319(a) Observed 1 chair in B hall, 2 chair in C hall and 1 chair in D hall needing cleaning.

Violations

CDI=Corrected During Inspection

R=Repeat Violation

VR=Verification Required

Violation Item	Demerits	Violation Description	CDI	R	VR	Comments
8	2	Facilities conveniently located, clean and in good repair	No	No	No	Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed soiled toilet in room 14 and 23. REPEAT Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed soiled showers in room 14 and 9.
33	1	Linen changed when soiled. Soiled linen handled properly	No	No	No	Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed soiled linens in rooms 14, 9, 23, and 55. Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b). Observed soiled linen cart in hall B and D unlabled.
35	1	Patient contact items in good repair, properly stored, cleaned and disinfected	No	No	No	Patient contact items that become contaminated during use shall be cleaned and disinfected after each use. 15A NCAC 18A .1319 (c). Observed hair in rollers and combs in the salon. REPEAT