Premises Information


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Name

WHITE OAK MANOR - CHARLOTTE

Address

4009 CRAIG AV

City/State/ZIP

CHARLOTTE

28211

Premise Type

40 - Rest/Nursing Homes

County

Mecklenburg

Inspection Date

1/9/2014

Final Score @ Grade

General Comments

3. -Observed wall damage in room E15.-Observed dining room being repaired due to a pipe that burst a few days ago. The base boards have been removed, fans are blowing to dry the walls, and a cleaning/repair company is presently working onsite.Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.15. Observed no back flow preventer on the shower wands in room E15 and S30. Provide back flow preventer on all shower wands throughout,Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).19. Observed pink build up in the ice machine in the S Nourishment room.Ice machines, buckets, other containers, and scoops shall be cleaned on a regular schedule such that they are kept free of scum, rust, mold or other contamination. 15A NCAC 18A .1314 (b).28. Observed bag of clothes stored on the closet floor in room W17, and a bag of pads on the closet floor in room E25.All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). •43. Observed a inaccurate thermometer in the refrigerator in the S Hall Nourishment room (red line not showing properly).All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b).Juanita, Raymond, and Lauren present throughout the inspection.

Violations

CDI=Corrected During Inspection

R=Repeat Violation

VR=Verification Required

Violation Item	Demerits	Violation Description	CDI	R	VR	Comments
5	1	Ambient air temperature 65 to 85 F, equipment clean	No	No	No	Observed the AC/Heat unit filters collecting dust in rooms on each hall.Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).
8	2	Facilities conveniently located, clean and in good repair	No	No	No	-Repeat Non-Compliance: Observed rusting toilet chairs in S30, E15, E6, and W8.-Repeat Non-Compliance: Observed soiled toilet seats in rooms S30 and S9.-Observed no toilet seat on nor chair over the toilet in room W20.Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). -Observed shower stretcher in Men's Shower room on W Hall in disrepair & shower head collar separating from the wall on E Hall Shower room.Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f).-Observed a slow draining handsink in staff restroom on E hall. Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
32	1	Furniture clean and in good repair. Mattresses clean, dry, odor free	No	No	No	-Observed torn mattress in room S30.-Observed cabinets drawers collecting food debris in S Hall Nourishment room-Observed the refrigerator gasket torn in the S Hall Nourishment room.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	2	Linen changed when soiled. Soiled linen handled properly	No	No	No	Repeat Non-Compliance: Observed soiled and/or holes in the bedding in rooms S30, S18, E25 and E6.**Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. See rule .1319 (b).
36	1	Approved utensils and equipment, cleaned and sanitized	No	No	No	-Observed pink build up in the ice machine on the S Hall.-Observed the oven drawer in the Activity room collecting old food debris.-Observed the interior of the refrigerators in the S Hall Nourishment room and the Pantry on the W Hall collecting residue and in need of cleaning.**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. See rule .1320 (c).