Premises Information


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Name

AUTUMN CARE OF CORNELIUS

Address

19530 MT ZION PY

City/State/ZIP

CORNELIUS

28031

Premise Type

40 - Rest/Nursing Homes

County

Mecklenburg

Inspection Date

7/11/2017

Final Score @ Grade

95.50

General Comments

NO POINTS WERE TAKEN FOR THE FOLLOWING: #3 - Observed wall damage in room 504 and in the equipment storage room on the 500-600 hallway. **Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. #8 - Observed feces on toilet chair in the bathroom of room 504. **Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). #13 - Observed one room in facility reach 117F at hand sink. No other hot water temperatures reached higher than 106F. **Maintain the hot water at all resident accessible hand washing sinks and bathing facilities within the temperature range of 100°F to 116°F. 15A NCAC 18A .1312 (e). #33 - Observed minor stains on bed pad in room 204 and a stain on sheet in room 504. **Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). #36 - Observed black build-up around the nourishment station freezers where the gasket seals. **Non-food contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. See rule .1320 (c). #43 - Observed patient refrigerator in room 403 without a thermometer. **All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b).

Violations

CDI=Corrected During Inspection

R=Repeat Violation

VR=Verification Required

Violation Item	Demerits	Violation Description	CDI	R	VR	Comments
11	1	Hand sinks used only for intended purpose	No	No	No	REPEAT Observed ice in hand sinks of nourishment stations. Ensure hand sinks are used for hand washing only and not disposing of ice/drinks. **Except for the stipulations stated in rule .1312 (d), hand washing sinks shall only be used for hand washing. 15A NCAC 18A .1312 (d).
16	1	Quantitiy and hot water sufficient, backup water supply plan	No	No	No	REPEAT Observed no information on back-up water supply plan on how facility will dispose of bodily waste, how dishes will be washed and sanitized, and how food will be prepared. **Observed an incomplete backup water supply plan. Provide a written plan that meets all parts of 15A NCAC 18A .1313 (f).
19	1	Ice protected, dispensed, equipment clean in good repair	No	No	No	Observed pink build-up on ice shoots in nourishment stations. **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	0.50	Adequate storage, area clean, items properly stored	No	No	No	REPEAT Observed single-service cup lids being stored right beside the hand sink on the 500-600 hallway nourishment station. Observed cleaning needed on the exterior cabinets and cabinet handles of nourishment stations and PT kitchen. All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a). 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). .
32	1	Furniture clean and in good repair. Mattresses clean, dry, odor free	No	No	No	Observed debris collecting under sheets on top of mattresses in resident rooms. Observed stains on mattress in room 204 and 504. Observed pillows ripping in need of replacement room 504. Mattresses shall be kept clean, dry, and odor free. 15A NCAC 18A .1319 (a). 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).