Davis Health Care Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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 REDACTED] 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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Davis Health Care Center in Wilmington, NC inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Wilmington, NC, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Davis Health Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.