Davidson Health & Rehab Center

Inspectors wroteBased 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).

Inspectors wroteBased 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. The Unit Manager called the order for the stat (immediately) x-ray of the right hip to the mobile imaging provider instead of the computerized ordering system which further delayed transfer to the hospital for evaluation and treatment. [...]

Inspectors wroteBased 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. Resident #1 was transferred via Emergency Medical Services (EMS) to the hospital where an x-ray indicated the resident had a right hip fracture. [...]

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to mark medications with opened-on or discard-by dates and failed to maintain medication refrigerator temperatures within the recommended range. This was for 5 of 6 areas reviewed for medication storage (Medication Carts #1, #4 and #5, and medication storage room refrigerators for Granny's Place and Lillian's).

Inspectors wroteBased on observations and staff interviews, the facility failed to label, date, and seal food items left open to air and stored for use in 1 of 1 walk-in refrigerator and failed to label and remove expired food items stored for use 1 of 1 walk-in freezer. These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to provide cueing assistance during a meal as specified in the resident's plan of care. Resident #90 was seated at a table in the main dining room with her meal tray in front of her not eating while other residents at other tables were eating their lunch. This deficient practice affected 1 of 8 residents reviewed for dignity.

Inspectors wroteBased on observation and staff interviews, the facility failed to protect residents' private healthcare information by leaving confidential medication information unattended, visible, and accessible to others on the computer screen for 1 of 5 medication carts observed (100 hall medication cart).

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure a resident room was in good repair and failed to maintain a clean and sanitary conditions in a resident room. The deficient practice was evidenced for 2 of 8 residents (Resident #67 and Resident #83) observed for a safe, clean and homelike environment on 1 of 4 resident halls (200 hall). a. An initial observation was completed on 08/25/25 at 10:33 AM of Resident #67 and Resident #83's room. The observation revealed a hole in the wall at the corner of Resident #83's headboard that measured approximately 11.5-inch x 8 inches with sheetrock exposed. On the wall to the left side of Resident # 83's bed paint was peeling off the wall between the bottom of the window frame and the packaged terminal air conditioner (PTAC) unit. The area of peeling paint extended was the length of the PTAC unit. [...]

Inspectors wroteBased on record review, Resident Representative (RR) and staff interviews, the facility failed to provide a written grievance response summary for 3 of 3 residents reviewed for grievances (Residents #9, #70 and #91).

Inspectors wroteBased on record review, and resident, family member and staff interviews, the facility failed to protect a resident's right to be free from staff to resident abuse when Nurse Aide (NA) #1 slapped Resident #74's hand when she became combative after removing her from another resident's room. This was for 1 of 1 resident reviewed for employee to resident abuse (Resident #74).

Inspectors wroteBased on record review and interviews with staff, the facility failed to notify the State Mental Health Authority after a resident diagnosed with a serious mental illness experienced a change in condition. This deficient practice affected 1 of 1 resident reviewed for (PASRR) Preadmission Screening and Resident Review (Resident #91).

Inspectors wroteBased on record review and staff interviews, the facility failed to develop a comprehensive person-centered care plan for 1 of 26 residents reviewed for comprehensive care plans (Resident #55).

Inspectors wroteBased on record review, resident, Medical Director and staff interviews, the facility failed to initiate physician orders on admission for the care of a surgical wound for 1 of 2 residents reviewed for quality of care (Resident #100).

Inspectors wroteBased on record reviews, observations, and staff interviews, the facility failed to ensure the enteral tube feed (a method of supplying nutrition through a feeding tube that goes directly into the stomach or small intestine) was infusing per the active physician's order for Resident #78. In addition, the facility failed to store a plastic enteral feeding syringe with the plunger separated from the barrel of the syringe which had the potential for bacterial growth and contamination. The deficient practice affected 1 of 1 resident reviewed for enteral feeding management (Resident #78).

Inspectors wroteBased on record review, observations, and staff and Medical Director interviews, the facility failed to have oxygen in use signage on the door (Resident #10) and failed to administer oxygen at the prescribed rate for 2 of 3 residents reviewed for respiratory care (Resident #56 and Resident #10).

Inspectors wroteBased on record review, Medical Director and staff interviews, the facility failed to discontinue a scheduled acetaminophen (used to relieve mild to moderate pain) order when a new order for scheduled Hydrocodone-acetaminophen (used to relieve moderate to severe pain) was received. This was for 1 of 6 residents reviewed for unnecessary medications (Resident #70).

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to maintain an accurate Medication Administration Record (MAR) for the documentation of supplemental oxygen for 2 of 3 residents reviewed for medical record accuracy (Resident #10 and Resident #56). 1. A review of the active physician orders for Resident #56 revealed an order dated 04/11/24, for oxygen (O2) at 2 liters per minute (L/min) via nasal cannula (NC) to keep O2 Saturation at 92% or above, every shift, day shift 7:00 AM-7:00 PM, evening shift 7:00 PM-7:00 AM. Review of Resident #56's August 2025 Medication Administration Record (MAR) revealed oxygen was signed off as being administered on day shift at 2L/min on 08/25/25 and 08/26/25 by Nurse #8. Night shift was signed off as being administered by Med Aide #2. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to educate and offer the pneumococcal (pneumonia) and influenza (flu) immunizations on admission (Resident #83) and failed to maintain a resident's medical record of refusal for the pneumococcal (pneumonia) immunization as well as education regarding risk and benefits of refusing the immunization (Resident #63). This occurred for 2 of 5 residents reviewed for immunization (Resident #63 and Resident #83).a. Resident #83 was admitted to the facility on [DATE]. Resident #83's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated his cognition was severely impaired and the pneumococcal and influenza immunizations were not offered. Resident #83's immunization record revealed no documentation that he had been offered, given, or refused the pneumococcal or influenza immunizations. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to educate and offer Resident #83 the COVID-19 vaccine on admission and failed to maintain a resident's record of refusal, acceptance, or if contraindicated for the COVID-19 vaccine for 1 of 5 residents reviewed for COVID-19 vaccination status (Resident #83). Resident #83 was admitted to the facility on [DATE]. Resident #83's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated his COVID-19 vaccination was not up to date. Review of Resident #83's medical records revealed no documentation that the COVID-19 vaccine was offered, contraindicated, administered, or refused. No documentation that the COVID-19 vaccine education was provided, and no documentation of previous COVID-19 vaccines received. An interview was conducted on 08/28/25 at 11:40 AM with the Assistant Director of Nursing (ADON). [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. A reasonable person would experience fear and intimidation from being abused in their home environment.

Inspectors wroteBased on record review and staff interviews the facility failed to provide care in a safe manner which resulted in a resident (Resident #21) falling from the bed. One of two falls from bed resulted in Resident #21 being sent to the emergency department for a laceration to her forehead that required 5 stitches. This was for 1 of 5 residents reviewed for accidents.

Inspectors wroteBased on staff interviews and record review, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of medications for Resident #16 and #45, indwelling catheter for Resident #57, and dental status for Resident #18. This was for 4 of 20 residents reviewed for MDS accuracy.

Inspectors wrote3a. Resident #7 was admitted on [DATE] with diagnoses of Cerebral Vascular Accident (CVA) with right sided hemiplegia and aphasia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7 had severe cognitive impairment and required maximum to total staff assistance with her activities of daily living (ADLs). Review of Resident #7's current care plan last revised 7/14/24 did not include a care area for assistance with ADLs but a review of the care plan from the previous computer program used prior to April 2024 included a care plan for ADL assistance. An interview was completed on 7/25/24 at 12:06 PM with the MDS Nurse. She stated her assistant left in February 2024 and had not been replaced until recently and in the interim remote staff helped with entering care plans. [...]

Inspectors wroteBased on observation, staff, resident and Responsible Party (RP) interviews and record review, the facility failed to have sufficient dietary staff to prepare resident meals resulting in nursing staff preparing resident's breakfast on 7/20/24 and on 7/21/24, the resident's lunch meal not being prepared and delivered to the dining room and onto the halls as scheduled resulting in late meals. This was for 2 of 5 days of the state survey and affected residents receiving meal trays from the kitchen.

Inspectors wroteBased on observations, test tray tasting, and interviews with staff, residents, and the Regional Registered Dietician (RD), the facility failed to serve food that was palatable in taste and appealing in appearance to 4 of 4 residents reviewed for food (Resident #84, Resident #23 Resident #13 and Resident #17).

Inspectors wroteBased on observation, staff and resident interviews and record review, the facility failed to serve the lunch meal at the posted time on 7/21/24 in the main dining room and on 3 of 3 halls (100 hall-Lillan's Way, 200 hall-Greene's Commons and 300 hall-Granny's Place).

Inspectors wroteBased on observation and staff interviews, the facility failed to date leftover food items in the walk-in refrigerator and also failed to store raw meat below fresh produce in the walk-in refrigerator. Raw and thawing meat should be stored below food items to prevent cross-contamination. This was for 1 of 2 observations completed of the walk-in refrigerator and had the potential to affect food served to residents.

Inspectors wroteBased on record review, observations, resident, and staff interviews the facility failed to provide incontinent care in a manner to maintain the residents' dignity for Resident #71. A reasonable person expects to be treated with respect and dignity by their caregivers in their home environment. This deficient practice was for 1 of 4 residents reviewed for dignity (Resident #71).

Inspectors wroteBased on record review, and family member, physician and staff interviews, the facility failed to meet the resident's care needs upon discharge by not ensuring the needed medical equipment was provided for 1 of 1 resident (Resident #95) reviewed for a safe and orderly discharge.

Inspectors wroteBased on observations, staff interview and record review, the facility failed to develop an individualized person-centered comprehensive care plan in the area of a range of motion for Resident #7. This was for 1 of 20 residents reviewed for comprehensive care planning.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to obtain Physician orders for the use of a right resting hand splint and for a pommel cushion (a cushion used to improve posture and hip positioning). This was for 1 of 2 reviewed for professional standards (Resident # 7).

Inspectors wroteBased on observations, record review, resident, and staff interviews the facility failed to provide nail care and incontinence care for 2 of 5 residents reviewed for activities of daily living (ADL) (Resident #71 and #7).

Inspectors wroteBased on record review, observation, and interviews with the Wound Care provider and staff, the facility failed to discontinue an order for a healed venous stasis ulcer on the lower extremity and initiate a new order for protective skin care to a healed venous stasis ulcer on the lower extremity (Resident #40). This was for 1 of 1 resident reviewed for well-being.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to ensure the low air loss mattress was set according to the resident's weight for 1 of 2 residents (Resident #57) reviewed for pressure ulcers.

Inspectors wroteBased on record reviews, Medical Director and staff interviews, the facility failed to hold blood pressure medications as ordered by the physician for 1 of 5 residents reviewed for unnecessary medications (Resident #19).

Inspectors wroteBased on observation and staff and resident interviews, the facility failed to display pertinent State Agencies and other advocacy group information in an accessible and visible location. The observation occurred for 3 of 5 days of the recertification survey.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to post accurate staffing information as compared to the daily staff schedule for licensed and unlicensed nursing staff for 24 out of 32 days (6/20/24 to 7/2/24, 7/5/24 to 7/9/24 and 7/12/24 to 7/17/24). The facility also failed to ensure the daily nurse staffing sheets were completed and posted for 4 out of 30 days reviewed (7/18/24, 7/19/24, 7/20/24 and 7/21/24) for staffing.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to have complete and accurate medical records in the area of wound care. This was for 1 of 2 residents (Resident #40) reviewed for wound care.

Inspectors wroteBased on record review and resident, staff, Medical Director, and Pharmacist interviews, the facility failed to acquire a medication ordered for administration for a newly admitted resident resulting in multiple doses of the prescribed medication being missed for 1 of 1 resident (Resident #545) reviewed for the provision of pharmaceutical services to meet the resident's needs. Findings Included: Resident #545 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus with diabetic neuropathy (weakness, numbness, and pain from nerve damage) and peripheral vascular disease (symptoms include numbness and cramping). Physician order dated 6/23/23 read pregabalin (a medication used to treat nerve and muscle pain) oral capsule 75 milligrams (mg) by mouth two times a day for pain related to peripheral vascular disease. The start date was 6/23/23 at 9:00 P.M. [...]

Inspectors wroteBased on record review and resident, staff, Medical Director interviews, the facility failed to prevent a significant medication error by failing to administer a prescribed nerve pain medication to a resident resulting in six doses of medication being missed for 1 of 1 resident (Resident #545) reviewed for medication errors. Findings Included: Resident #545 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus with diabetic neuropathy (weakness, numbness, and pain from nerve damage) and peripheral vascular disease (symptoms include numbness and cramping). Physician order dated 6/23/23 read Pregabalin (a medication used to treat nerve and muscle pain) oral capsule 75 milligrams (mg) by mouth two times a day for pain related to peripheral vascular disease. The start date was 6/23/23 at 9:00 P.M. [...]

Inspectors wroteBased on record review and staff interview, the facility filed to provided required dementia management training for 1 of 5 (NA#1) Nurse Assistants (NA) reviewed for required training.

Inspectors wroteBased on record review, observation, Physician and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of disposition (Resident #94), range of motion (Resident #26), and restraints (Resident #79). This was for 3 of 24 resident records reviewed.