Premises Information


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Name

WILLOW RIDGE ASSISTED LIVING

Address

2040 MILTON RD.

City/State/ZIP

CHARLOTTE

28215

Premise Type

40 - Rest/Nursing Homes

County

Mecklenburg

Inspection Date

9/18/2018

Final Score @ Grade

General Comments

No Points Deducted: 6. Observed black buildup (what appears to be mold) on the walls and ceiling in the small 200 shower room. Clean. Moisture shall be controlled such that there is no evidence of microbial growth on interior surfaces and objects. 15A NCAC 18A .1311 (d). 9. Observed wheelchairs stored in the shower room on the 200 hall. Follow the rule below. Toilet rooms shall not be used for storage. See rule .1312 (b). 24. Observed a live roach in room 102. Continue pest control. Effective measures shall be taken to keep flies, rodents, cockroaches, and other vermin out of the establishment and to prevent their breeding or presence on the premises. 15A NCAC 18A .1317 (a). 26. -Observed the grass high in the outside common area. Cut. -Observed a stove, couch, etc on the ground behind the dumpster. Remove from premises. The premises shall be kept neat, clean, and free of litter. 15A NCAC 18A .1317 (c). ED, Ms. Shimika Bowers present during the inspection. Report and Backup Water Supply Plan Checklist emailed to wral.adm@affinitylivinggroup.com Inspection lead by Nykesse Roberts. Sarah Coppa present during the inspection.

Violations

CDI=Corrected During Inspection

R=Repeat Violation

VR=Verification Required

Violation Item	Demerits	Violation Description	CDI	R	VR	Comments
3	2	Walls and ceilings cleanable, clean, good repair	No	No	No	Repeat: -Observed water damage to the back/bottom of the doors in the small shower rooms- peeling and splitting. Repair. -Observed the popcorn ceiling peeling in room 101. -Observed the cove base tiles missing in the 200 spa near the handsink. Replace. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.
4	2	Lighting at least 10 foot candles 30 inches above floor	No	No	No	Repeat: Observed insufficient lighting in residence rooms throughout the building. 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).
5	1	Ambient air temperature 65 to 85 F, equipment clean	No	No	No	Repeat: Observed the AC unit filters in every room very dusty. Clean. 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: -Observed pink residue on shower chair in both shower rooms. -Observed pink and black build up in shower grout in shower rooms. Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). -Observed the handsink separated away from the wall- 200 small shower room. Resecure and regrout. Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
14	1	Disinfectant accessible, properly used	No	No	No	-Observed no cleaning chemical in the shower room on the 100 hall. A cleaning detergent and an EPA registered hospital disinfectant shall be accessible to all bathing areas. 15A NCAC 18A .1312 (f). -Per an employee on the 100 hall, she cleans the shower equipment by spraying the chemical on and immediately washing it off. -Per another employee on the 200 hall, she sprays soap on the equipment and washes it off. *Per the Virex 256 bottle, the contact time is 10 minutes. The manufacturer's instructions shall be followed for cleaning equipment with pumps. See rule .1312 (f).
16	1	Quantitiy and hot water sufficient, backup water supply plan	No	No	No	Observed no backup water supply plan present. Checklist emailed to ED (Ms. Bowers). Observed an incomplete backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f).
17	1	Water fountains clean, good repair, properly regulated	No	No	No	Observed heavy black buildup on the water fountain. Clean. Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a).
32	2	Furniture clean and in good repair. Mattresses clean, dry, odor free	No	No	No	Repeat: -Observed stains and debris on chairs and couches as well as under the cushions in the common areas. -Observed ripped mattresses in rooms 101 & 208. -Observed torn and/or stained pillows in rooms 101 & 213. -Observed stained chair cushion in room 213. -Observed handles missing from the drawer in room 205. -Observed torn mattress cover in room 102. 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	1	Linen changed when soiled. Soiled linen handled properly	No	No	No	Repeat: -Observed stains on the sheets in room 102. Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). -Observed bins of soiled linen stored uncovered in the 100 hall spa, and soiled linen on the floor in the 200 hall spa. Soiled linen shall be placed in a covered container or bag at the point of use and stored and handled so as to contain and minimize aerosolization of and exposure to any waste products. 15A NCAC 18A .1319 (b).
35	1	Patient contact items in good repair, properly stored, cleaned and disinfected	No	No	No	Repeat: -Observed adult diapers on the floor in storage room and room 208. -Observed hair in curlers and drawers in the beauty salon. Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).