Premises Information


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Name

UNIVERSITY PLACE NURSING AND REHABILITATION CENTER

Address

9200 GLENWATER DR

City/State/ZIP

CHARLOTTE

28262

Premise Type

40 - Rest/Nursing Homes

County

Mecklenburg

Inspection Date

5/1/2018

Final Score @ Grade

General Comments

NO POINTS WERE TAKEN FOR THE FOLLOWING: #4 - Observed light out in janitor closet 100 hallway. Observed damaged light in rehab spa. Observed damaged window in the OT room. **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). #14 - Observed head house keeper state that chemical used for toilets and bathing equipment is left for a contact time of 1 minute. Manufacturers instructions states 10 minute contact time is required for this chemical to be used as a disinfectant. Observed disinfectant to be inaccessible in spas. House keeping stated disinfectant was stored in locked cabinet within but no one knew the combination. Observed therapist in rehab room state that the contact time for disinfectant wipes was one minute. Manufactures label states 2 minutes is required. **A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). #26 - Observed trash cans being stored behind dumpster with garbage and standing water in them without lids. Observed dead insects on floor in need of cleaning in electrical closet on 100 hall. **There shall be no fly or mosquito breeding places, rodent harborages, or undrained areas on the premises. 15A NCAC 18A .1317 (c).

Violations

CDI=Corrected During Inspection

R=Repeat Violation

VR=Verification Required

Violation Item	Demerits	Violation Description	CDI	R	VR	Comments
1	1	Floors easy to clean, no obstacles, drains where needed	No	No	No	REPEAT Observed floor damage throughout hallways and in 106. **Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b).
3	2	Walls and ceilings cleanable, clean, good repair	No	No	No	REPEAT Observed touch-up paint needed throughout facility including patient rooms, med rooms, spark hallways, dining rooms, and janitor closets. Observed peeling wallpaper in 116, spark unit, 408, 403, 300 hall, 503, 1008, and 800 hall. Observed wall damage throughout facility including patient rooms and restrooms, spark unit, activity rooms, rehab room, OT room, and dining rooms. Observed base boards detaching from walls in 100 hallway, spark unit, and rose dining. Observed soiled walls in spark unit. Observed ceiling damage in spark unit, 300 hall, and laundry room. Observed doors damaged throughout including patient rooms, spark unit, bathrooms, and dining rooms. Observed hand rails peeling in spark unit. **Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
8	2	Facilities conveniently located, clean and in good repair	No	No	No	REPEAT Observed soiled toilet seat in 116, Observed hoppers to be soiled in need of cleaning throughout soiled utility rooms. 309, and 1008. Observed caulking needed around sink in 116, and caulking needed around base of toilet in 106, 403, and 700. Observed build-up in the shower grout and broken tiles in shower of spark unit spa. Observed damaged shower curtains in the rehab spa. 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).
18	2	Drinking utensils properly handled	No	No	No	REPEAT Observed water pitcher labeled 116A and 116B on same water pitcher in 116. Observed water pitcher in 805 without label. **Label all disposable water pitchers with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a).
28	1	Adequate storage, area clean, items properly stored	No	No	No	REPEAT Observed diapers being stored on the floor in the med prep room on 100 hall, and storage on floor in rehab storage closet. Observed patient personal items being stored on the floor in the spark unit storage room. Observed temporary storage rooms on 1000 hall with excessive storage, packed to tightly for regular cleaning. Observed items being stored within the splash zone of hand sink in med prep 100 hall and spark unit. Observed chemical spray bottle being stored with paper towels on janitor cart in 100 hall. Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a). All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
30	1	Medication carts clean, sharps containers affixed, food and utensils handled properly	No	No	No	REPEAT Observed pill crushers in need of cleaning on med carts throughout. **Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c).
32	2	Furniture clean and in good repair. Mattresses clean, dry, odor free	No	No	No	REPEAT Observed damaged furniture in patient rooms throughout where drawers are difficult to open and off the tracks, in the restorative activity room, library, and lobby. Observed peeling laminate on cabinets and patient closet doors throughout and damaged cabinets in 116 and 106. Observed bed remote with debris and build-up in the cracks and crevices in 106. Observed heavily soiled drawers with food debris in 309. Observed cabinets in need of cleaning in rose dining room and 309. Observed torn rehab equipment in rehab room and peeling bed positioning wedge in 805. Observed stained and soiled pillows in rooms 116 and 408. **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 Observed stained sheets throughout rooms. Observed beds to be made up with debris left in sheets in rooms 116, 106, 908, and 805. Observed stained divider curtains in 116, 403, 700, and 805. Observed damaged and worn linen in rehab room. **Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).
34	1	Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately	No	No	No	REPEAT Observed wipes being stored directly in contact with clean linen on clean linen cart of 900 hall. Observed clean linen commingled with toileting supplies in 700 hall clean linen closet. Observed clean linen shelving in need of repair in several closets. **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).
42	2	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	No	No	No	Observed pudding cups on med carts that state "Keep Refrigerated." Nurses stated that pudding is opened and kept for 24 hours on carts to use at med pass. Puddings were not being kept under temperature control and were at room temperature today. Puddings must remain under temperature control or must be labeled and discarded after two hours when removed from temperature control. Puddings voluntarily discarded today. **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).