Davis Health Care Center

Inspectors wroteBased on observations, record review and interviews with staff, Nurse Practitioner and Responsible Party (RP), the facility failed to protect the residents' right to be free of resident-to-resident physical abuse for 2 of 2 residents (Resident #110 and Resident #14) reviewed for abuse. Resident #110 (a female resident with severe cognitive impairment) had a history of following Resident #14 (a male resident with cognitive impairment) around the facility, getting close to him, and entering his room at night. Staff reported Resident #14 would get irritated and try to get away from Resident #110. On 6/5/26 Resident #110 was observed poking Resident #14 in the face with her finger and yelling. Resident #14 grabbed Resident #110's wrist, followed by Resident #110 grabbing Resident #14's left arm digging in her nails, and Resident #14 hitting Resident #110 on her face. [...]

Inspectors wroteBased on observations, record review, staff and Nurse Practitioner interviews, the facility failed to ensure two cognitively impaired residents were free from the use of physical restraints. A staff member applied gait belts around the residents' abdomen and secured the belts to the back frames of their wheelchairs, restricting their freedom of movement and preventing them from independently rising from the chairs. The residents were unable to remove the belts on their own. There was no physician's order, assessment, care plan or clinical justification for restraint use. This deficient practice occurred for 2 of 2 residents (Resident #3 and Resident #95) reviewed for restraint use. A reasonable person would have felt fear, loss of autonomy, helplessness, and a loss of dignity when physically restrained in a wheelchair without the ability to remove the device or move freely.

Inspectors wroteBased on record review, and staff and resident interviews, the facility failed to communicate the efforts to address and resolve concerns that were reported during Resident Council Meetings for 6 of 8 months of Resident Council Meeting minutes reviewed (October 2025, November 2025, December 2025, January 2026, February 2026, March 2026, April 2026, May 2026).

Inspectors wroteBased on record review, and resident, staff, the Pharmacy Quality Assurance Representative, Pharmacy Nurse Consultant and Nurse Practitioner interviews, the facility failed to protect resident's right to be free from misappropriation of narcotic pain medications (oxycodone). This deficient practice occurred for 2 of 2 residents reviewed for misappropriation of controlled medications (Resident #125 and Resident #87).

Inspectors wroteBased on record review, and staff and Nurse Practitioner interviews the facility failed to implement its abuse policy and procedures in the areas of reporting to the Administrator, reporting to the regulatory agency, law enforcement and Department of Social Services Adult Protective Services and provide protection for: 1.) An injury of unknown origin in a cognitively impaired resident (Resident #14) who sustained fractures of the left radius and ulna without any documented or reported fall, and was not reported to the Administrator. 2.) Two (2) separate incidents of resident-to-resident abuse between Resident #14 and Resident #110 in a special care unit that resulted in injuries to both residents and a hospital evaluation for Resident #110. [...]

Inspectors wroteBased on record review, Psychiatric Nurse Practitioner interview, and staff interviews, the facility failed to permit a resident to return to the facility after being transferred to the hospital for a psychiatric evaluation due to aggressive behaviors toward other residents for 1 of 2 residents reviewed for hospitalization (Resident #1).

Inspectors wroteBased on observations, staff and Nurse Practitioner (NP) interviews, and record review, the facility failed to ensure a safe environment free of accident hazards for 1 of 5 residents reviewed for accidents (Resident #25), when a can of WD-40 (a penetrating oil used to lubricate metal surfaces and highly flammable) was observed in Resident #25's room in an area easily accessible to other cognitively impaired residents, creating the potential for accidental ingestion, misuse, or exposure. This deficient practice had the potential to affect all residents on the unit.

Inspectors wroteBased on record review, and interviews with staff, Nurse Practitioner and Psychiatric Nurse Practitioner, the facility failed to address a psychiatric Nurse Practitioner recommendation to increase the medication trazadone (an antidepressant used to manage restlessness and anxiety and is used as a sleep aid) for a resident (Resident # 110) diagnosed with dementia who had a known pattern of wandering behaviors and nighttime sleep disturbance. This deficient practice was for 1 of 1 resident (Resident # 110) sampled for dementia care.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to record the opened date on an insulin pen and discard an expired bottle of an ophthalmic solution (eye drops), according to the manufacturer's guidelines, and discard an expired bottle of a proton pump inhibitor (a medication that decreases the amount of acid produced in the stomach). This was observed on 1 of 3 medication carts (200 hall medication cart) reviewed for medication storage. Findings Included: Review of the manufacturer's guidelines for Insulin Glargine (Lantus) pens instructed to discard 28 days after opening. Review of the manufacturer's guidelines for Polyvinyl 1.4 % ophthalmic solution instructed to discard 90 days after opening. An observation of the 200-hall medication cart on 6/17/26 at 10:30 AM along with Nurse #10 revealed the following: [...]

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to implement the infection control policy and procedures for Enhanced Barrier Precautions (EBP) when two staff members (Nurse #9 and NA #7) were observed providing direct care activities to Resident #42 who had a Stage IV pressure ulcer on her sacrum and Nurse #9 was observed not changing her gloves and hand sanitizing prior to going from a dirty area to a clean area during wound care. This occurred for 2 of 3 staff members observed for infection control practices.

Inspectors wroteBased on observation, record review, and interviews with staff, resident, Physician and Wound Care Specialist, the facility failed to identify an environmental hazard and supervise Resident #1. Resident #1 was newly admitted to the nursing home, severely cognitively impaired and blind. On 10/11/25, Nurse Aide (NA) #1 placed Resident #1, who was seated in his wheelchair, in front of the lit fireplace in the dining room after he expressed feeling cold. NA #1 then left to assist another nurse aide, leaving Resident #1 unsupervised. While unattended, Resident #1 tipped his wheelchair over backward, falling against the fireplace. His head, back, and shoulders came into contact with the hot mesh grate. Resident #1 yelled out. Resident #2 was on the other side of the fireplace and yelled for help from staff. NA#1 responded and alerted Nurse #1. Resident #1 told NA #1 his head was burning. [...]

Inspectors wroteBased on observations, and staff, Ombudsman, Director of Dining Services, Certified Dietary Manager, Club Cook, Compliance Coordinator, and Registered Dietitian (RD) interviews, and record review, the facility failed to have no greater than a 14-hour lapse between the provision of a substantial evening meal and breakfast the following day for residents served their meals on 5 of 8 meal carts (Club area Cart-1&2; Pavilion area Cart; Haven area Cart, and River Bend area Cart) utilized for meal service. This practice had the potential to affect all the residents (91 of 91) in the facility for meal delivery.

Inspectors wroteBased on record review, and staff and resident interviews, the facility failed to provide a resolution and communicate the efforts to address grievances reported during Resident Council meetings for 10 of 12 months reviewed (June 2024, July 2024, August 2024, September 2024, October 2024, November 2024, December 2024, January 2025 February 2025, March 2025).

Inspectors wroteBased on record review, and staff interviews, the facility failed to coordinate a plan of care with the Hospice provider for 2 of 2 residents (Resident #54 and #21) reviewed for Hospice care.

Inspectors wroteBased on record review and staff interviews, the facility failed to transmit Annual Minimum Data Set (MDS) assessments (Resident #14, Resident #58, and Resident #27) and a Discharge MDS assessment (Resident #80) to the Centers for Medicare and Medicaid Services (CMS) system 14 days after completion of the assessment for 4 of 23 residents reviewed for MDS assessments.

Inspectors wroteBased on observations, record review and staff interviews the facility failed to treat a resident with dignity and respect when Nurse #3 spoke to a resident (Resident #41) in a demeaning way when she demanded the cognitively impaired resident to pick up food and dishes that the resident had thrown on the floor for 1 of 2 residents observed for dignity. This action would have caused a reasonable person psychosocial harm such as feelings of shame, humiliation, agitation, and degradation.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to ensure perishable food items were labeled with a date when stored in 1 of 1 walk in refrigerator, and 1 of 1 reach in refrigerator. These practices had the potential to affect food served to residents.

Inspectors wroteBased on record review, observations, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) Program failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation survey of 6/21/21 and the recertification and complaint investigation survey of 8/9/22. This was for one recited deficiency on the current recertification and complaint investigation survey of 2/8/24 in the area of food preparation and storage (F812). The continued failure during three federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance program.

Inspectors wroteBased on record review and staff interviews the facility failed to complete a comprehensive Minimum Data Set (MDS) admission assessment within the regulatory time frame as specified in the Resident Assessment Instrument (RAI) manual for 1 of 1 resident reviewed for completion of a comprehensive MDS assessment (Resident # 219).

Inspectors wroteBased on observations and staff interviews, the facility failed to dispose of an expired box of acetaminophen 650 milligram suppositories (Rehab medication storage room) and an expired bottle of tuberculin solution (Riverbend medication storage room) for 2 of 3 medication storage rooms observed.

Inspectors wroteBased on record review and staff interview, the facility failed to complete the Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) assessment within the regulatory timeframe as specified in the Resident Assessment Instrument (RAI) manual for 1 of 1 resident reviewed for Significant Change in Status Assessments MDS assessments (Resident #12). Resident #12's SCSA MDS assessment was completed 27 days after the assessment reference date which was past the specified 14-day timeframe.

Inspectors wroteBased on record review and staff interview, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within the regulatory timeframe as specified in the Resident Assessment Instrument (RAI) manual for 2 of 12 residents reviewed for quarterly MDS assessments (Resident #52 and Resident #22).