Davidson Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Davidson Health & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF693Jul 16, 2025

  Based on record reviews and interviews with staff, Medical Director, Nurse Practitioner (NP) and emergency room Physician, the facility failed to provide treatment and services to replace an old, discolored, and leaking gastric feeding tube after 5/04/25 when approximately 5 inches of the tube broke off during routine feeding tube care. In addition, the facility failed to schedule an appointment with a gastroenterologist to assess for a feeding tube replacement. On 6/18/25, the feeding tube site was found with approximately 25 maggots in the skin surrounding her feeding tube during care. […]

• Actual harm, isolatedF580Feb 26, 2026

  Based on record review and staff and Nurse Practitioner interview, the facility failed to immediately notify the Responsible Party (RP) and the physician of Resident #1 experiencing a fall with reported pain immediately after the fall and throughout the day. This failure to immediately notify the physician resulted in a delay in diagnostics and necessary medical treatment for a fractured hip. The result of the x-ray that followed was the diagnosis of a fractured hip that resulted in the resident being sent out for medical treatment. This deficient practice affected 1 of 3 residents reviewed for notification of change (Resident #1). […]

• Actual harm, isolatedF684Feb 26, 2026

  Based on record review and interviews with the resident, staff, mobile imaging provider Representative, and the Nurse Practitioner, the facility failed to identify the seriousness of a resident's unwitnessed fall and immediate reports of pain and complete and document comprehensive assessments following the fall to determine the need for transfer to a higher level of care. The Nurse did not complete a thorough assessment of Resident #1 before the resident was transferred from the floor to the bed. In addition, there were no comprehensive nursing assessments of the resident's condition documented in the medical record. […]

• Actual harm, isolatedF697Feb 26, 2026

  Based on record review and resident, staff, Responsible Party, and Nurse Practitioner interviews, the facility failed to provide effective pain management for a resident who reported acute severe pain rated a 10 out of 10 (0 meaning no pain and 10 meaning the worst pain the resident experienced) of the right hip after experiencing an unwitnessed fall. Despite receiving 2 doses of 1,000 milligrams (mg) of acetaminophen, the pain and discomfort the resident experienced caused the resident to cry out and wince in pain with movement. Resident #1 stated she told everyone she was in a lot of pain that day and she was not offered anything additional for pain relief. […]

• Actual harm, isolatedF600Oct 16, 2024

  Based on record review, and staff and resident interviews, the facility failed to protect a resident's right to be free from abuse for 1 of 1 resident reviewed for abuse (Resident #2). Resident #2's cognitively intact roommate (Resident #3) stated on 10/3/24 he was in the room while the curtain was pulled and he heard Nurse Aide (NA) #1 and Resident #2 fussing back and forth. NA #1 told Resident #2 you're not going to keep hitting me followed by an audible smack. After the incident, Resident #2 was identified by staff with a bright red hand mark on her right hip/thigh, she appeared agitated, and stated to NA #3 she hurt me. Resident #2 did not have the cognitive capacity to express an adverse psychosocial outcome. […]