Premises Information


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Name

PINES AT DAVIDSON, THE

Address

400 AVINGER LN

City/State/ZIP

DAVIDSON

28036

Premise Type

40 - Rest/Nursing Homes

County

Mecklenburg

Inspection Date

6/27/2016

Final Score @ Grade

General Comments

Judy Green (Nursing) was present during the inspection. The following resident rooms were inspected: 105, 158, 166, 168, 197, 271, 288, and 299. NO POINT DEDUCTION: 2. Observed the closet floor in the Brown Dining room, and the carpet was stained in room 197. **Keep all flooring clean. 15A NCAC 18A .1309 (a). 4. Observed light bulbs needed replacing in the 1st floor spa room, and the memory care clean linen closet. **Repair lights 16. Observed the back-up water supply plan was not complete; missing quantity of water per resident per day, and how resident clothing would be washed. **Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d). 33. Observed one resident room with stained bed sheet. **Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). 40. Observed a container of pimento cheese brought by visitor was not dated in the activity room refrigerator. ** 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).

Violations

CDI=Corrected During Inspection

R=Repeat Violation

VR=Verification Required

Violation Item	Demerits	Violation Description	CDI	R	VR	Comments
3	1	Walls and ceilings cleanable, clean, good repair	No	No	No	Observed ceiling and wall damage in some rooms: 299, 288, memory care spa, and 168. Observed the wall needed cleaning near bed in room 197. **Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.