Davis Health Care Center
Davis Health Care Center in Wilmington, NC — inspection on October 20, 2025.
Found 1 citation. 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
jeopardy to resident health or safety
Director stated that he installed the covers over the switches that controlled the fireplaces on 10/15/25 when he was informed of the incident. An interview was conducted with the DON on 10/17/25 at 11:45 AM.
The DON stated that she was an interim DON and just started in the position the week of the incident.
The DON stated she received a call from the Nursing Supervisor on 10/11/25 and was informed that Resident #1 fell backwards and had sores on the back of his head due to the fall near the fireplace.
The DON stated that Resident #1 was not supervised when he was placed close to the fireplace and then tipped his wheelchair over backwards striking the back of his head and shoulders on the fireplace.
The DON stated she instructed the Nursing Supervisor to turn the fireplace off and that she did not know what else to tell her.
The DON stated that she did not instruct the Nursing Supervisor to call the Maintenance Director to turn the heat source off for the fireplace at the time as she had not thought about it nor did she instruct her to ensure that all fireplaces in the facility were turned off.
The DON stated the following day, 10/12/25, she received a call from the Admissions Coordinator who informed her that Resident #1 had sustained second degree burns when he fell.
The Admissions Coordinator visited Resident #1 at the hospital on [DATE] and received the information regarding his condition and the burns.
The DON stated that on 10/12/25 after receiving the information that Resident #1 sustained second degree burns, she did not call the Nursing Supervisor or Maintenance Director to follow up with further interventions regarding the fireplace.
The Administrator was notified of the immediate jeopardy on 10/16/25 at 2:05 PM.The facility provided the following credible allegation of immediate jeopardy removal:Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 10/11/2025, it was identified that Resident #1, was placed at dining room table in his wheelchair with his back facing the lit fireplace due to Resident #1 stating he was cold. It is unknown how long the fireplace had been on. Resident #1 was eating a breakfast sandwich and drinking coffee at the dining room table. Resident #1 is able move around in his wheelchair; however, his mobility varies from day to day.
Shortly thereafter, NA #1 left the dining room area to assist a colleague with resident care regarding a transfer. NA #1 informed the resident she would return shortly after assisting another resident.
Nursing Home Administrator re-interviewed NA #1 and nurse on 10/17/2025 for clarification regarding positioning of Resident #1. Resident #1 tipped his wheelchair over, landing on the ground while remain[TRUNCATED]
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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.