Davidson Health & Rehab Center
Davidson Health & Rehab Center in Lexington, NC — inspection on February 26, 2026.
Found 3 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
According to the RP, he had believed the injury happened just before he arrived at the facility, but he found out instead he had not been notified that Resident #1 had fallen hours earlier in the day.
The RP indicated the ambulance arrived to take the resident to the local hospital while he was at the facility.A further review of Resident #1's facility electronic medical record revealed an order from the physician dated 1/28/26 at 2:34 PM to send Resident #1 to the local hospital for evaluation and treatment, stat (immediately).A review of the local hospital treatment record dated 1/28/26 at 3:54 PM indicated Resident #1 presented to the emergency room (ER) with deformity and tenderness to the right hip. An x-ray of the right hip completed 1/28/26 revealed a comminuted, displaced, and impacted right hip fracture (a severe injury where the bone shatters into three or more pieces, the fragments are out of alignment, and the broken ends are driven into each other).
The hospital record indicated the resident denied hitting her head when she fell, but due to the history of an existing subdural hematoma (bleeding near the brain) with CT (computed tomography) evidence of recent bleeding, the resident was admitted to the trauma intensive care unit for monitoring and neurological checks. Resident #1 was then transferred to a secondary hospital for surgical repair of the right hip fracture.The Director of Nursing (DON) was interviewed on 2/24/26 at 2:30 PM who stated Nurse #1 failed to report Resident #1 had fallen during her shift on 1/28/26.
The DON stated she reviewed the 24-hour shift report and noted the time 5:45 was written and underlined next to Resident #1's name on the report, but there was no documentation in the medical record to indicate what had happened.
She further stated that Nurse #1 did not report the fall to the oncoming shift.
According to the DON, the staff should have done what was right for the resident and completed an assessment of the resident and notified the provider the resident had a fall.
The Nurse Practitioner (NP) was interviewed on 2/23/26 at 4:41 PM and stated she was notified by the Unit Manager during the morning of 1/28/26 that Resident #1 had fallen but was unsure of the time she received the call.
She stated she gave orders to obtain an x-ray of the resident's right hip due to reports of pain.
The NP indicated if she had known the severity of the resident's pain level, she would have possibly given different treatment orders.
345066 02/26/2026
Davidson Health & Rehab Center 4748 Old Salisbury Road Lexington, NC 27295
According to the DON, the order for the mobile x-ray should have been entered into the computerized ordering system to avoid delay in diagnosing Resident #1's hip fracture.The Nurse Practitioner (NP) was interviewed on 2/23/26 at 4:41 PM and stated she was notified by the Unit Manager during the morning of 1/28/26 that Resident #1 had fallen but was unsure of the time she received the call.
She stated she gave orders to obtain an x-ray of the resident's right hip due to reports of pain.
The NP indicated if she had known the severity of the resident's pain level, she would have possibly given different treatment orders for the resident to receive the correct level of care to treat her injury.The facility provided a plan of correction for past non-compliance, however upon review, the plan of correction was found to have been lacking the necessary information and was found to be incomplete.
345066 02/26/2026
Davidson Health & Rehab Center 4748 Old Salisbury Road Lexington, NC 27295
According to the ED note, Resident #1 was alert and oriented, and she declined analgesics (pain relieving medications) upon arrival. An x-ray of the right hip completed at the hospital 1/28/26 revealed a comminuted, displaced, and impacted right hip fracture (a severe injury where the bone shatters into three or more pieces, the fragments are out of alignment, and the broken ends are driven into each other). Resident #1 was then transferred to a secondary hospital for surgical repair of the right hip fracture.
The Director of Nursing (DON) was interviewed on 2/24/26 at 2:30 PM who stated Nurse #1 failed to report Resident #1 had fallen during her shift on 1/28/26.
The DON stated there was no documentation in the medical record to indicate what had happened to Resident #1.
The DON stated Nurse #2, who was assigned to Resident #1 from 7:00 AM to 7:00 PM on 1/28/26, was a new nurse, and she failed to document Resident #1's condition that day.
The DON indicated she assumed Nurse #2 assessed the resident.
The DON stated the physical therapist reported Resident #1 only reported pain when he touched the resident and if she was not being touched then Resident #1 did not complain of pain.
According to the DON, the staff should have completed an assessment of the resident and notified the provider the resident had a fall and was in pain.The Nurse Practitioner (NP) was interviewed on 2/23/26 at 4:41 PM and stated she was not at the facility on the morning of 1/28/26 and she was notified by the Unit Manager that morning Resident #1 had fallen but was unsure of the time she received the call.
She stated she gave orders to obtain an x-ray of the resident's right hip due to reports of pain.
The NP indicated if she had known the severity of the resident's pain level, she would have possibly given different treatment orders.The facility provided a plan of correction for past non-compliance, however upon review, the plan of correction was found to have been lacking the necessary information and was found to be incomplete.