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

6/3/2019

Final Score @ Grade

General Comments

NO POINTS: #9: Toilet rooms shall not be used for storage. See rule .1312 (b). Observed wheelchairs, jerry chairs stored in bathrooms. #12: Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). Observed several paper towels dispensers empty in locked rooms like med rooms, soiled utility rooms, etc CDI-filled #14: 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). Observed staff did not know to clean with a detergent before disinfection step. Disinfectants used had 10 minute contact times. Staff members did not know contact times. (through discussion with several staff). #15: Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d). Observed no backflow preventers in beauty salon or 1 or 2 shower wands in spa rooms. #16: Observed an incomplete backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f). Observed incomplete back-up water supply plan. New ED had one started, not completed. #21: The rooms, enclosures, designated areas, and containers shall be adequate for the storage of all solid wastes accumulating on the premises. 15A NCAC 18A .1316 (c). Observed meat bones, grease and trash on ground outside compactor door. Keep this area clean so pests/flies are not attracted. #30: Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c). Observed soiled med carts (facility has new med carts but haven't been switched to yet). Observed soiled pill crushers, keep clean. Call for reinspection when ready 980-314-1620 ask office assistant to enter a service request

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	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). Observed tiles in roll in showers in spa rooms with black build up in grout. Needs better cleaning All floors subject to flood-type cleaning shall be of nonabsorbent materials, shall be sloped to drain and provided with floor drains. 15A NCAC 18A .1309 (b). `Observed grout not sealed in remodeled spa rooms. Seal grout before opening for use.
3	1	Walls and ceilings cleanable, clean, good repair	No	No	No	Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed walls and ceilings in disrepair throughout, except newly remodeled areas (facility under remodel)
5	1	Ambient air temperature 65 to 85 F, equipment clean	No	No	No	Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). Observed dusty fan in laundry room. Keep fan clean. Ambient air temperatures shall be maintained in the range of 65°F to 85°F. 15A NCAC 18A .1311 (c). Observed air conditioner broken in small portion of building. Keep occupants out of stuffy areas.
8	2	Facilities conveniently located, clean and in good repair	No	No	No	Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed shower beds and shower chairs with hair/build-up. Clean and disinfect between patients, including the under sides. Shower door track loose in room 505. Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed fecal matter on the undersides of several toilet seats. Clean more thoroughly including undersides. Observed several broken or missing toilet paper roll holders throughout building. Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b) Observed hand sinks not being cleaned on old PT side of building. Some of the old sink fixtures are corroded. 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). Observed refrigerator used for patient foods in storage room without hand sink. Observed refrigerator and ice machine in room without hand sink, unlabeled room off lobby. Any area where food is stored must have a hand sink. Keep hopper clean.
19	1	Ice protected, dispensed, equipment clean in good repair	No	No	No	All ice machines and storage chests which are accessible to the residents and the public shall be automatic ice dispensing machines. 15A NCAC 18A .1313 (b). Observed unprotected ice chest in hallway. Ice where residents or visitors can access have to be automatic dispensing. 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). Observed heavy build-up in ice machine and ice scoops and ice scoop holders with scale build-up. Scoops and scoop holders need to go to kitchen for cleaning daily.
28	0.50	Adequate storage, area clean, items properly stored	No	No	No	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). Observed phlebotomy supplies, bathing supplies, crash cart supplies disorganized. In memory care spa room wash basin containing new and used toothbrushes, hair brushes, razors, etc. stored intermingled. Same spa room also had an obstructed hand sink and whole bags of clean linens.
32	1	Furniture clean and in good repair. Mattresses clean, dry, odor free	No	No	No	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 debris under cushions of common furniture. Mattress in room 908 stained, cover unzipped. Observed bedside and over bed tables in disrepair throughout (being replaced during remodel)
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 sheets and pillow cases rooms 812 and 908.
36	1	Approved utensils and equipment, cleaned and sanitized	No	No	No	Cooking surfaces of equipment shall be cleaned at least once each day. 15A NCAC 18A .1320 (c). Observed couple of rusted microwaves that need replacing. Clean spills from refrigerators. Observed one water pitcher on med cart with pink residue, wash in kitchen every 4 hours.
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	Medications shall be stored in a manner which will not contaminate food or food products such as in separate covered containers or in separate refrigerators. 15A NCAC 18A .1323 (a). Observed medications stored above food in fridge in Memory care med room.
47	1.50	Hands properly washed or decontaminated	No	No	No	Handwashing shall include a vigorous rubbing together of all surfaces of lathered hands for at least 10 seconds followed by thorough rinsing under a stream of water and drying with individual disposable towels or hand drying devices. 15A NCAC 18A .1324 (b). Observed employee helping resident to bathroom/shower without hand washing afterwards (gloves still on)