University Retirement Community at Davis

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and secure storage of medications for two of 17 sampled residents (Resident 8 and Resident 20), for a census of 36 when:1a. Resident 8's unlabeled medication was left at bedside;1b. Resident 8's discontinued controlled medications were stored in the medication cart;2. Resident 20's expired medication was stored in the medication room; and,3. Two bottles of expired vitamins were stored in the medication room. These failures increased the potential for medications to be accessible to other residents, increased the potential for drug diversion, and administration of vitamins with decreased effectiveness.

Inspectors wroteBased on observation, interview and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety for a census of 36 when: 1. Food items in the refrigerator were observed to be uncovered; and,2. Potentially hazardous food (food that requires time/temperature control for safety to limit the growth of organisms capable of causing a disease) had inaccurate labeling. These failures had the potential to result in foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and follow an effective infection prevention and control program for a census of 36 when:1. Resident 40's CPAP (continuous positive airway pressure- ensures uninterrupted breathing and oxygen) mask and distilled water used for the treatment were not properly stored;2. Staff did not consistently follow transmission-based precautions (TBP) for Resident 37;3. Resident 20's distilled water used for CPAP treatment was observed unlabeled and on the floor; 4. Dirty linens were observed on the floor of the laundry room; and5. The facility management was not informed of positive Legionella (a type of bacteria found in [NAME] that can cause a serious type of lung infection) testing results. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call light systems were accessible for two of 17 sampled residents (Resident 23 and Resident 25) when:1. Resident 25's call light was observed under the bed and not within reach; and2. Resident 23's shower room call device did not have a string to operate. These failures had the potential to negatively affect Resident 23 and Resident 25's safety by preventing the residents from communicating requests for assistance when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 17 sampled residents (Resident 40) was treated with dignity and the right to privacy when Resident 40's urinary catheter drainage bag was not completely covered while in the dining room. This failure increased the potential for Resident 40 to experience emotional or psychological distress. A review of the admission Record indicated Resident 40 was admitted [DATE] with diagnosis including Parkinson's disease (a brain disorder causing problems with movement and balance) with dyskinesia (involuntary, uncontrolled, & repetitive muscle movements) and generalized muscle weakness. Further review of Resident 40's clinical records indicated the following information:- An Order Summary Report dated 9/9/25 indicated Urinary Catheter: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the electronic record reflected the resident's treatment decisions for one of 17 sampled residents (Resident 2) when Resident 2's code status (a status indicating what should be done if the resident had no pulse and not breathing) was not indicated on the electronic medical record and was not available to staff, and had no physician order. This failure decreased the facility's potential to respond appropriately based on Resident 2's choices in the event of a medical emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status for one of 36 sampled residents, (Resident 32) when Resident 32's unplanned weight loss was not assessed and managed. This failure had the potential for Resident 32 to experience continued weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide safety and supervision for one of three sampled residents (Resident 1), when the resident was left in the bathroom unattended and unsupervised during toileting. This failure could have contributed to Resident 1 ' s fall that resulted in right hip fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment with adequate supervision for one of three sampled residents (Resident 1), when Resident 1 eloped (left facility unsupervised and without prior authorization) from facility, fell, and then was moved after the fall before being assessed by a licensed nurse (LN). This failure resulted in Resident 1 experiencing a left orbital fracture (fracture of the bones of the eye socket) and contusion (bruise) of right lower leg and had the potential for further injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was safe and accurate provision of pharmaceutical services, for four of 13 sampled residents (Resident 89, Resident 5, Resident 23 and Resident 31) when: 1. Resident 89's medication was not available for administration as scheduled; 2. Resident 5's order for bladder treatment was not followed as ordered; and 3. There was no accurate accountability of controlled medications (high potential for abuse or addiction) for two of four residents (Resident 23 and Resident 31). These failures increased the potential for Resident 89 and Resident 5 to have unresolved symptoms and the potential for abuse, misuse, and diversion of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and supplies were stored and labeled in accordance with current acceptable professional standards, for a census of 36, when: 1. A medication container labeled Gabapentin (medication used to treat seizures and pain) was in the medication room on the countertop; 2. An opened bottle of sterile water with Gentamicin (antibiotic used to treat bladder infection) was stored in the refrigerator without a resident's name; 3. There was incomplete documentation of room temperature in the medication room; 4. The discontinued non controlled medications were stored in usable form; 5. There were expired supplies in the medication room; and, 6. An opened bottle of mineral oil was in the medication cart unlabeled with resident name or date. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure recipes were used and followed during meal preparation when: 1. The Beef Fajitas were prepared without following the recipe with measured ingredients, and 2. The Beef Fajitas were not served according to portion sizes. This failure had the potential to alter the nutritional value of the meals and to affect the health status of the 36 residents receiving food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare foods according to professional standards for food safety when: 1. opened food products were not labeled/ dated; 2. food products past the best by dates were not discarded; 3. white and grayish powder accumulation and an unknown liquid was found on the lid of food bins; 4. floor in dry storage room found with onion peels; 5. steak knife was found in the dry storage room; 6. a small potato was found in the pasta bin; 7. cutting boards were badly scraped; 8. beard net was not worn as required, and 9. a pitcher of cranberry juice was served past the labeled consumed by date. These failures had the potential to increase the risk of foodborne illnesses for a total of 36 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was developed and implemented for two of 13 sampled residents (Resident 9 and Resident 18) when: 1. Resident 9 had no care plan for the use of an anticoagulant (blood thinner, medication to prevent blood clots); and 2. Resident 18 had no care plan for the incidence of a fall. Theses failures increased the potential for Resident 9 and Resident 18 to have unmet needs due to a lack of monitoring.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of quality was maintained for one of 13 sampled residents (Resident 25) when the attending physician was not notified of Resident 25's episodes of hypoglycemia (low blood sugar) as ordered. This failure had the potential to cause a delay in the management of Resident 25's change in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and prevent hazards at specific points of food handling for total of 25 residents when: 1. Staff did not wear a beard net while handling food; and 2. A can opener was found with rust and in use. These failures had the potential to place residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate pressure ulcer management was provided for one resident (Resident 9), for a census of 25 when: 1. The low air loss mattress (LAL, designed to distribute the body weight and help prevent skin breakdown) was not provided as ordered; and 2. There was missing and incomplete wound assessments. These failures increased the risk for wound deterioration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were followed when the oxygen tubing for one resident (Resident 15) was left uncovered after use and was not changed as scheduled, for a census of 25. This failure increased the potential to cause respiratory infection for Resident 15.