Davidson Health & Rehab Center
Davidson Health & Rehab Center in Lexington, NC — inspection on August 28, 2025.
Found 16 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
his or her rights.
observations, record review, and resident and staff interviews, the facility failed to provide cueing
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.The findings included:Resident #90 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, dysphagia (difficulty swallowing), and memory deficit following other cerebrovascular disease.Review of a quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #90 to be severely cognitively impaired without behaviors.
She was assessed as requiring set-up or clean-up assistance with eating.According to the active care plan for Resident #90 dated 6/28/25, the resident had an ADL (activities of daily living) self-care performance deficit related to Alzheimer's. An approach read Resident #90 needed set-up and cueing assistance with meals.On 8/25/25 at 12:15 PM an observation was conducted in the main dining room during lunch. Resident #90 was noted to be sitting by herself in a wheelchair at a table in the main dining room while four other residents were seated at a table to her right eating their meal. Resident #90 had a tray of food set up sitting on the table in front of her that was untouched.
The resident did not attempt to eat during the observation.
Nurse Aide (NA) 6 and NA #7 were observed seated at a table at the back of the dining room.
Each NA had one resident sitting beside each of them assisting those residents with eating.
Neither NA was observed assisting Resident #90. NA #6 and NA #7 were interviewed on 8/25/25 at 12:38 PM. NA #6 stated there were usually only 2 staff members in the dining room at mealtimes. NA #6 and NA #7 stated Resident #90 only occasionally needed cueing and assistance with her meals. On 8/26/25 a continuous observation from 12:30 PM to 1:17 PM was conducted in the main dining room during lunch. Resident #90 was noted to be sitting by herself at a table in the dining room with a tray of food set up sitting on the table in front of her, and it was untouched.
The resident did not attempt to feed herself during the observation.
There were three residents eating lunch at a table to Resident #90's right side. NA #3 and NA #4 were observed sitting at a table in the back of the dining room assisting two residents with eating.
Each NA was assisting one resident with an empty seat on the other side of the NA. At 12:33 PM on 8/26/25 an interview was conducted with NA #4 and NA #3. NA #4 stated if more than one resident needed assistance with eating then she could have one resident sit at her right side and one resident sit at her left side to assist both during mealtimes.
She stated Resident #90 only occasionally needed assistance with meals and would sometimes feed herself if her tray was set up in front of her. NA #3 agreed that NA staff could assist two residents during mealtimes. NA #4 and #3 were not aware Resident #90's care plan specified she required cueing with her meals. At 1:17 PM NA #4 completed assisting the resident she had been helping and then approached Resident #90 and began assisting her with eating her meal.
The Director of Nursing (DON) was interviewed on 8/28/25 at 11:20 AM and stated if a resident needed cues to eat, they should be placed closer to the NAs in the dining room who were there to assist residents with eating.
She stated a resident should not have to wait to eat their meals while others were assisted.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
345066 08/28/2025
Davidson Health & Rehab Center 4748 Old Salisbury Road Lexington, NC 27295
Federal health inspectors cited Davidson Health & Rehab Center in Lexington, NC for a deficiency under regulatory tag F-F0583 during a standard health inspection conducted on 2025-08-28.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Keep residents' personal and medical records private and confidential.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Davidson Health & Rehab Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-23.
expected any room that needed repairs to be reported to the Maintenance Director so the repairs
department call outs.
345066 08/28/2025
Davidson Health & Rehab Center 4748 Old Salisbury Road Lexington, NC 27295
Federal health inspectors cited Davidson Health & Rehab Center in Lexington, NC for a deficiency under regulatory tag F-F0585 during a standard health inspection conducted on 2025-08-28.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Davidson Health & Rehab Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-23.
was satisfied with the care that she received.
The family member indicated she was made aware of
no additional concerns. On 8/28/2025 at 1:59 PM, an additional interview occurred with a family
staff explained in detail what happened then she felt better.
The family member reported that she felt like the facility handled the situation appropriately by terminating the employee and making a report to the authorities.
The family member stated she was not nervous about Resident #74's care at the facility and felt that staff provided good care to Resident #74. On 8/27/25 at 8:07 AM, an interview occurred with DON.
The DON reported that the NA #1 called her crying and stated that she had to tell her something she had done.
The DON indicated that per NA #1's statement, Resident #74 was going into another resident's room and NA #1 went to get her out. NA #1 reported that Resident #74 was fighting her, and she smacked her on the hand. DON reported that NA #1 was a good NA and had never done anything like that before.
The DON stated she explained to NA #1 that it was not acceptable and that NA #1 was not to go back into the building. DON reported that she called Nurse #1 on duty and asked her to go and take NA #1's statement in person so that it could be reported and Nurse #1 also called the family to notify them regarding the incident. the interview further revealed Nurse #1 also did a head to toe of the resident and did a complete sweep of the unit to check the other residents.
DON reported that there were no other concerns reported. On 8/28/2025 at 11:42 AM, an interview occurred with the Administrator.
The Administrator reported she was notified by NA #2 who witnessed the situation regarding the allegation of abuse.
The Administrator stated that this was reported immediately, and NA #1 was removed from the facility.
The Administrator revealed that NA#1 was immediately suspended and then her employment was terminated.
The Administrator reported that the police department was notified, and an investigation was initiated.
The Administrator stated she was able to view video footage at the time that revealed that Resident #74 had just been taken to the nurse's station when she became combative towards NA #1 which is when NA #1 was then seen smacking the resident's hand down.
The Administrator stated that NA #1 was a good employee, however, they do not tolerate any type of abuse towards a resident.
The Administrator reported that there have been no further staff to resident abuse concerns since this incident on 6/29/25.
345066 08/28/2025
Davidson Health & Rehab Center 4748 Old Salisbury Road Lexington, NC 27295
Federal health inspectors cited Davidson Health & Rehab Center in Lexington, NC for a deficiency under regulatory tag F-F0646 during a standard health inspection conducted on 2025-08-28.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Davidson Health & Rehab Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-23.
Federal health inspectors cited Davidson Health & Rehab Center in Lexington, NC for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-08-28.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Davidson Health & Rehab Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-23.
Federal health inspectors cited Davidson Health & Rehab Center in Lexington, NC for a deficiency under regulatory tag F-F0658 during a standard health inspection conducted on 2025-08-28.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Davidson Health & Rehab Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-23.
Federal health inspectors cited Davidson Health & Rehab Center in Lexington, NC for a deficiency under regulatory tag F-F0693 during a standard health inspection conducted on 2025-08-28.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Davidson Health & Rehab Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-23.
Federal health inspectors cited Davidson Health & Rehab Center in Lexington, NC for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2025-08-28.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Davidson Health & Rehab Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-23.
Federal health inspectors cited Davidson Health & Rehab Center in Lexington, NC for a deficiency under regulatory tag F-F0757 during a standard health inspection conducted on 2025-08-28.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure each resident’s drug regimen must be free from unnecessary drugs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Davidson Health & Rehab Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-23.
included: Take action if temp is out of range -too warm (above 46 F) (degrees Fahrenheit) or too cold
manufacturer(s).2.
Record the out-of-range temps and the room temp in the Action area on the bottom
health department for guidance. 4.
Document the action taken on the attached Vaccine Storage Troubleshooting Record.
The refrigerator temperature logs were reviewed and revealed the following low temperatures documented and initialed by staff on the [DATE] log:[DATE]: 8 AM 34 [DATE]: 7 AM 33 / 7PM 34 [DATE]: 7:20 AM 31 / 3:50 PM 30 [DATE]: 8 AM 32 /5 PM 33 [DATE]: 8 AM 34 /5 PM 32 [DATE]: 9 AM 34 /6 PM 33 [DATE]: 8 AM 33 /5 PM 34 [DATE]: 7 AM 34 / 7 PM 33 [DATE]: 7 AM 32 / 7 PM 33 [DATE]: 7:50 AM 34 / 4:15 PM 32 [DATE]: 7 PM 34 [DATE]: 7 AM 32 / 7PM 33 [DATE]: 7 AM 34 / 7 PM 33 [DATE]: 7 AM 34 / 7 PM 34 [DATE]: 7 AM 32 / 7 PM 31 [DATE]: 7:20 AM 33 /6:50 PM 32 [DATE]: 7:05 AM 34 / 6:00 PM 34 [DATE]: 9 AM 34 / 5 PM 33 [DATE]: 9 AM 32 / 5 PM 32 [DATE]: 76:55 AM 33 / 5:20 PM 32 [DATE]: 7 AM 32 / 7 PM 31 [DATE]: 7 AM 33 / 7 PM 34 [DATE]: 7 AM 32 / 6:30 PM 34 There was no documentation of the action taken on the temperature log.
Medications were observed in the refrigerator in the refrigerator in the medication room for Lillian's on [DATE]. On [DATE] at 2:00 PM an interview with Nurse #2 was conducted during the medication room observation.
She stated she had checked the refrigerator temperature at the beginning of the shift and adjusted it and would check the temperature again later and make sure it was in range. An interview was conducted on [DATE] at 2:46 PM with the Director of Nursing (DON).
She stated she expected the nurses to mark medications when they're opened and discard them when they expired.
She stated she would expect the nurse to adjust the temperature of the refrigerator if it were out of range and then notify the nurse manager of the concern.
345066 08/28/2025
Davidson Health & Rehab Center 4748 Old Salisbury Road Lexington, NC 27295
serve food in accordance with professional standards.
open to air and stored for use in 1 of 1 walk-in refrigerator and failed to label and remove expired food
residents.The findings included: Accompanied by the Dietary Manager, an observation was made of the walk-in refrigerator on 8/25/25 at 9:32 AM.
The following items were stored in the refrigerator: -One undated box of turkey sausage that was open and partially used with the remaining contents unwrapped and exposed to air. -One undated package of Danishes open and partially used with the remaining contents unwrapped and exposed to air. An observation of the walk-in freezer revealed the following stored item:-One large plastic, zippered storage bag containing unlabeled and uncooked ground meat dated 7/7/25.
The Dietary Manager was interviewed on 8/25/25 during the kitchen tour at 9:32 AM. He stated food should be wrapped once it's opened and labeled with the contents and date it was opened. He indicated food should be used or discarded within seven days after opening.
The Dietary Manager stated he did not work over the past weekend, and he did not have an opportunity to check the refrigerator and freezer Monday morning due to printing meal tickets for the breakfast service. On 8/25/25 at 12:35 PM the Administrator was interviewed and stated foods should be labeled with their contents and opened dates and stored in the refrigerator and freezer correctly.
Federal health inspectors cited Davidson Health & Rehab Center in Lexington, NC for a deficiency under regulatory tag F-F0842 during a standard health inspection conducted on 2025-08-28.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Davidson Health & Rehab Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-23.
Federal health inspectors cited Davidson Health & Rehab Center in Lexington, NC for a deficiency under regulatory tag F-F0883 during a standard health inspection conducted on 2025-08-28.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Develop and implement policies and procedures for flu and pneumonia vaccinations.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Davidson Health & Rehab Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-23.
Federal health inspectors cited Davidson Health & Rehab Center in Lexington, NC for a deficiency under regulatory tag F-F0887 during a standard health inspection conducted on 2025-08-28.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 16 deficiencies cited during this inspection of Davidson Health & Rehab Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-23.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.