Oct 27, 2026
97 / 100
· 7 violations
#2 · Walls and ceilings clean, good repair
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair.
Observed wall cover coming apart from the wall in the soiled room on side A in the OR.
#7 · Facilities provided, accessible, clean, good repair −2
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed blood/stains on hand sink in hall restroom in Adult ED. Observed soiled/stained toilet bowl in 7 floor-seclusion rooms, soiled bathroom floor in room 708. Need cleaning and keep clean. Observed slow draining hand sinks in staff restroom 6D, need repair. Observed soiled hand sink around basin and faucet throughout behavioral health restrooms, some hand sinks need caulking and keep good repair.
#10 · Handwashing facilities properly located and equipped
.1312 (d) Handwashing facilities shall be located in an institution in accordance with 10A NCAC 13B .5411, 10A NCAC 13D .3201, 10A NCAC 13F .0305, .1304, and 10A NCAC 13K .1109, .1204, as applicable. Institutions that do not have a handwashing facility located in all areas required by this Paragraph shall not be required to install handwashing facilities if the institution has an approved hand hygiene program.
Observed no paper towels at the dispenser in laundry room 7th floor behavioral health. No soap in the dispenser at nourishment hallway area sink on 6th floor behavioral health. Provide soap/paper towels at all hand sinks at anytime.
#11 · EPA registered disinfectants used according to manufacturers' instructions; approved testing methods and devices used
.1312 (e) EPA registered disinfectants shall be used in accordance with the manufacturer's instructions. When EPA registered disinfectants are mixed and prepared by institution employees, a measuring device, chemical testing device, or the methods and devices prescribed by the chemical manufacturer shall be used to prepare the concentration of chemicals in accordance with the disinfectant's label and the manufacturer's instructions. Observed 1 cart on BH 7 floor did not have disinfectant.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair −0.5
.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair.
Observed torn mattress and sticker residue in room 6 Adult ED. Observed tape residue on mattress in room 14 in Children's ED. Observed mattress peeling in room 7827 on 7F.
#38 · Food service equipment and utensils clean, good repair −0.5
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair.
Observed debris build-up on bottom of rear in freezer on unit 3SW. Clean. Observed debris on ice chute on Adult ED nourishment.
Observed soiled refrigerator need cleaning inside 7E refrigerator, cleaning the outside refrigerator and drink machine in 6D. Keep clean.
#43 · Food brought into the institution by employees or visitors of patients or residents properly stored, labeled and dated
.1321 (b) Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply as described in rule .1321 (a). Such food shall be labeled with the name of the resident or employee that the food belongs to and the date the food was brought into the institution. Labeling as required by this Rule shall not be required for food items stored in employee-designated or individual residents' refrigerators or rooms.
Observed patient food stored in refrigerator labeled with name and no date in unit 3SW nourishment
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Jun 16, 2026
95 / 100
· 8 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −1
1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair. Observed damaged/peeled floor tiles near soiled room in Labor and Delivery. Observed black residue on floor tiles in shower in room 767 on 7C.
#2 · Walls and ceilings clean, good repair
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. Observed wall scuffed / damaged in patient room #3104 in need of touch-up painting / repair.
#7 · Facilities provided, accessible, clean, good repair −1
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair.
- Observed soiled toilets with ring around the bowl, soiled sinks all around basin, drain, faucet need cleaning in Radiology, Radiology Holding, CT scan department, Flora department, Emergency Department. Observed slow drain need repair at public restroom ED, Flora department, Radiology Holding, ED area A-B. Observed sink need new caulking and repair in ED public restroom, ED nourishment sink in D area.
#8 · Toilet rooms free of storage, handwash signs posted
.1312 (b) A sign shall be posted in each toilet room for institution employees, directing them to wash their hands after each visit to the toilet room and before returning to work.
- Observed no hand washing sign in staff restroom in Endoscopy.
#10 · Handwashing facilities properly located and equipped
.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices.- Observed no soap available in soiled utility room ED- D area and no paper towels in soiled utility room in Endoscopy. Ensure to provide all hand washing supplies at all hand sinks at all time.
#16 · Hot water between 105°F and 116°F −3
.1313 (d) Institutions shall provide water heating facilities. Hot and cold running water under pressure shall be provided to carry out all operations. Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities. Observed hot water at 83F in neuro ICU. Observed automatic sink in room 6329 and soiled utility in intermediate ICU not operating. Observed hot water measured at 123F in CT scan 1, the entire unit of Endoscopy at 125F, and Flora restroom at 90F. REPEAT.
#20 · Ice protected and clean; dispensed properly; ice machines, scoops, containers; clean, good repair
.1314 (c) Ice shall be protected against physical, chemical, and biological contamination and shall be kept clean. Observed build up in ice chute of ice machine in NICU and in Mother/Baby nourishment.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair
.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair. Observed residue on shower curtain in 767 on 7C. Observed chair cushion ripped in room 802 on Mother/ Baby. Observed clean supply room in (3C) having soiled shelving in need of general cleaning. Observed toilet seat loose in BH 704.
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Apr 29, 2025
95 / 100
· 8 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free
1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair. Observed cleaning needed on floors in soiled utility rooms on 7th and 8th floors.
#2 · Walls and ceilings clean, good repair −1
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. - Observed wall damage in SPD. Observed damaged walls and build up on walls in soiled utility in ICU. Observed wall edging loose at entrance to Equipment storage in ICU. Observed stained ceiling tile in room just inside the door on unit 5D. Repeat. No escalation in points.
#7 · Facilities provided, accessible, clean, good repair −1
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed hand sink draining slow (end of hall in Endo near nuclear medicine hallway). Clean around hand sink faucets and toilets in Endo, ED, Radiology. Observed leaking tub faucet and cracked shower handle backing in room on 5D. Observed tub room with stained shower tiles in Neuro ICU. Repeat. No escalation in points.
#10 · Handwashing facilities properly located and equipped
.1312 (d) Handwashing facilities shall be supplied with soap and disposable towels or hand-drying devices. - Observed paper towel dispenser not operating in PICU 7.
#16 · Hot water between 105°F and 116°F −3
.1313 (d) Institutions shall provide water heating facilities. Hot and cold running water under pressure shall be provided to carry out all operations. Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities. Observed hot water 92-102F in ED guest restroom, ED B station, ED A station. 75-81F in Radiology ultrasound, CT scan, and 118F at Endo sink at end of hallway. 75-78F in room 735 on 7E. Observed hot water reach 99F in PACU and 120F in PICU 7. Observed 6F having 120F-121F at hand sinks throughout. Observed water at 118 in room at 5D. Observed Water at 119 in 5813. Repeat.
#21 · Approved sewage disposal
.1315 (a) All sewage originating from the institution shall be disposed of using a publicly operated sewage treatment plant or an individual sewage disposal system that meets the requirements of Section .1900 of this Subchapter. Observed mop sink in soiled utility in 5A clogged and not draining.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair
.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair. Observed tear on seat cushion in room 769. Work order submitted during the inspection. Observed damaged couch cushion and laminate under couch in 5813. Observed laminate on counter peeling in soiled utility in 5F.
#38 · Food service equipment and utensils clean, good repair
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed fridge, cabinets and microwave in need of cleaning in nourishment 2 on 5F. Observed microwave and fridge in need of cleaning in nourishment 1 of 5F. Observed cabinets in nourishment room in need of cleaning in CCU and 5C.
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