Davidson Health & Rehab: Meal Neglect Violation - NC
The same thing had happened the day before.
The resident, identified in inspection records only as Resident #90, had been admitted to the facility with Alzheimer's disease, dementia, dysphagia, and memory deficits. Her care plan, updated in June, was direct: she needed set-up and cueing assistance at every meal. Without someone prompting her, she would not eat.
On August 25, 2025, at 12:15 p.m., a state inspector walked into the main dining room during lunch. Resident #90 was sitting by herself in a wheelchair. Four other residents were eating at a table to her right. Her tray sat in front of her, untouched. She made no attempt to eat. Two nurse aides, identified as NA #6 and NA #7, were seated at a table in the back of the room, each helping one other resident. Neither was anywhere near Resident #90.
When inspectors spoke with the two aides at 12:38 p.m., NA #6 said there were usually only two staff members in the dining room at mealtimes. Both aides said Resident #90 only occasionally needed cueing and assistance. That assessment contradicted her care plan, which required cueing at meals without exception.
The inspector came back the next day.
On August 26, the observation ran from 12:30 p.m. to 1:17 p.m. Resident #90 was again sitting alone at a table. Again, her tray was in front of her. Again, it was untouched. Again, she did not attempt to feed herself. Three residents were eating at a table to her right. Two aides, NA #3 and NA #4, were at a table in the back assisting two other residents. Each aide had an empty seat on the other side of them.
At 12:33 p.m., inspectors interviewed NA #3 and NA #4. NA #4 explained that when more than one resident needed help eating, she could seat one resident on her right and one on her left and assist both at once. She acknowledged the approach was possible. She also said Resident #90 only occasionally needed help, and would sometimes feed herself if her tray was set up.
Neither NA #3 nor NA #4 knew that Resident #90's care plan required cueing at meals.
At 1:17 p.m., after finishing with the resident she had been helping, NA #4 walked over to Resident #90 and began helping her eat. By then, the resident had been sitting with her untouched food for 47 minutes.
The Director of Nursing, interviewed on August 28, said residents who needed cueing should be seated closer to the aides assigned to help with meals. She said a resident should not have to wait to eat while others were being assisted.
What she described was not what inspectors had observed on either day.
Dysphagia, the swallowing difficulty listed among Resident #90's diagnoses, carries real risks when meals are skipped or delayed. For a person with advanced Alzheimer's who will not initiate eating on her own, cueing is not a courtesy. It is the mechanism by which she eats at all.
The violation was classified as causing minimal harm or potential for actual harm, and affected one of eight residents reviewed for dignity during the inspection. The complaint inspection was completed August 28, 2025.
What the inspection record does not say is how many meals Resident #90 sat through before a complaint was filed, or how many times her tray was cleared away still full.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Davidson Health & Rehab Center from 2025-08-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
Davidson Health & Rehab Center in Lexington, NC was cited for neglect violations during a health inspection on August 28, 2025.
The same thing had happened the day before.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.