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

6/27/2022

Final Score @ Grade

87.50

General Comments

NO POINTS FOR THE FOLLOWING VIOLATIONS: #3. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed ceiling damage outside of room 403. #4. 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). Observed several lights not operating in spa room located within rehab unit. #11. Except for the stipulations stated in rule .1312 (d), handwashing sinks shall only be used for handwashing. 15A NCAC 18A .1312 (d). Per conversation with employee in memory care unit, she fills water up from handsink located in activity room, for pitcher of water. #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 back flow preventer device stored on shower wand in memory care spa room. #21. Solid waste containers, rooms, or designated areas shall be kept clean. 15A NCAC 18A .1316 (c). Observed liquid under compactor dumpster. EHS advises facility to clean liquid under compactor to help against rodents. EHS advises facility to ensure compactor does not have a hole. #40. 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). Observed container of food with name and no date in refrigerator located in nourishment room on 300 hallway. Per maintenance it was an employee’s food. *NOTE: ENVH Supervisor, Shawn Blackmon, was present during time of inspection. Greg Brown( Head of Maintenance), Jay Shifrin (Environmental Consultant), Eric Hudson (ENVH Manager). Report was went over witH Administrator, Coleen Anderson. Report emailed to: upl63-don@universityplacenursing.com

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 bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed detailed cleaning needed to spa rooms throughout facility (Observed black build up inside shower grout within spa rooms throughout facility). Observed white bathing mat with slits in shared spa room on 100 hallway. Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed several loose toilet seats throughout facility. Observed detailed cleaning needed to toilets throughout facility. (Toilet soiled room 403, toilet soiled room 1004, loose toilet room 704, brown staining on toilet seat in room 704). REPEAT VIOLATION.
9	1	Toilet rooms free of storage, hand wash signs posted	No	No	No	Toilet rooms shall not be used for storage. See rule .1312 (b). Observed storage in all shared spa rooms throughout facility to include, soiled linen, boxes of supplies, clothing, furniture, etc. Observed boxes stored inside of tub in rehab area. Per conversation with facility rehab area is currently not in use. EHS observed soiled linen and clothing stored on the floor in middle of rehab spa room. REPEAT VIOLATION
14	1	Disinfectant accessible, properly used	No	No	No	A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). Observed no EPA registered disinfectant accessible to all shared spa rooms throughout facility. Per housekeeping management, CNA clean shower rooms after each use, EHS was unable to get a clear answer on where the EPA disinfectant is held for access to CNA’s to clean. REPEAT VIOLATION.
16	2	Quantitiy and hot water sufficient, backup water supply plan	No	No	No	Observed an incomplete backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f). REPEAT VIOLATION.
19	2	Ice protected, dispensed, equipment clean in good repair	No	No	No	Ice shall be handled, transported, stored, and dispensed in such a manner as to be protected against contamination. 15A NCAC 18A .1314 (b). Observed ice chest stored in hallway unattended and not locked on 300 hallway. 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 pink build up inside ice machine located on 300 hallway nourishment room. REPEAT VIOLATION.
28	0.50	Adequate storage, area clean, items properly stored	No	No	No	All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). Observed patient contact items stored on the floor in rehab area storage closet. Observed brown blankets in large clear plastic bags stored on the floor in clean linen closet within memory care.
33	2	Linen changed when soiled. Soiled linen handled properly	No	No	No	Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b). Observed all green soiled linen carts throughout facility not labeled “soiled linen” Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed staining on linen in rooms 113, 114, and 1004. REPEAT VIOLATION.
34	2	Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately	No	No	No	All common linen including sheets, pillow cases, absorbent pads, towels, and wash cloths provided by the facility must be sanitized between users with an EPA registered laundry sanitizer or by other methods described in 15A NCAC 18A .1319 (b). Observed common linen’s being commingled with no documentation from facilities services, Ecolab, detailing the amount of sanitizer being pumped into system per cycle. 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). Observed clean linen carts throughout facility being stored commingled with an employees purse, hygienic items, gloves, diapers, etc. REPEAT VIOLATION.