Davis Health Care Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect two residents from resident-to-resident physical abuse. One resident had severe cognitive impairment, wandering, agitation, restlessness, and a history of entering another resident’s room at night and following him around the unit. The other resident had dementia with agitation, impaired memory, and a documented history of violent outbursts and behavioral problems related to cognitive impairment and delusions. Both residents lived in the special care unit and their rooms were across from each other. On 6/5/26, staff observed the cognitively impaired resident poking the other resident in the face and yelling. During the interaction, the other resident grabbed her wrist, she grabbed his arm and dug in her nails, and he hit her in the face. The resident had reddened areas to her face, and the other resident had scattered bruising and a small skin tear to his arm. Staff interviews showed the residents were frequently together, that the female resident often irritated the male resident by getting close to him, and that no effective intervention plan was implemented after this first altercation. On 6/7/26, a nurse heard yelling from the male resident’s room and found the female resident on the floor while the male resident stood over her, holding her by the hair and kicking her in the face. The female resident was sent to the ED for evaluation after a knot was noted on the back of her head; the ED workup found no acute findings. Interviews and record review showed staff had previously seen the female resident enter the male resident’s room, sleep in his bed, and wander into his room at night, and staff had expressed concern that something bad was going to happen between the two residents. The Administrator stated the altercations should not have occurred and that the facility was responsible for keeping the residents free from abuse.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure two cognitively impaired residents were free from the use of physical restraints when a staff member applied gait belts around their abdomens and secured the belts to the back frames of their wheelchairs. The residents, identified as Resident #3 and Resident #95, were unable to remove the belts on their own, and the belts restricted their freedom of movement and prevented them from independently rising from the chairs. There was no physician’s order, assessment, care plan, or clinical justification documented for restraint use. Resident #3 had diagnoses including dementia and generalized anxiety and was assessed as having moderately impaired cognition, with no physical or verbal behaviors toward others and no restraints noted on the MDS. Resident #95 had dementia and was assessed as having severe cognitive impairment, with no physical or verbal behaviors toward others and no restraints noted on the MDS. Neither resident’s care plan included any plan of care regarding restraints. Review of the electronic medical records showed no documentation of the incident, no physical assessments, no monitoring after the incident, and no physician’s order indicating a medical symptom for restraint use. During the incident, staff reported that the Clinical Coordinator placed the gait belts on the residents while they were in wheelchairs, and other staff observed the belts secured around the residents’ abdomens and attached to the backs of the wheelchairs. The Activity Director and Activity Assistant both stated they saw the residents restrained during a St. Patrick’s Day activity, and the Activity Assistant reported that Resident #95 was pulling at her shirt as if something was bothering her. The assigned nurse and nurse aide were aware of the belts, but no immediate action was taken at the time, and the residents remained in the belts for an extended period during the activity. The residents’ responsible parties stated the residents would not have wanted to be restrained and would have been scared or angry if restrained.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to communicate efforts to address and resolve concerns raised during Resident Council meetings over multiple months. Resident Council minutes documented repeated complaints about cold food, laundry not being returned, folded, or put away, the use of plastic silverware and paper plates, residents having to ask for desserts, staff being on cell phones or wearing earbuds during resident care, and residents not receiving help opening food containers or cutting food. In several monthly meetings, the minutes did not show that the facility provided a response to prior concerns or documented any follow-up with the council. The concerns were raised repeatedly from October 2025 through May 2026, including ongoing complaints about cold food and laundry issues, as well as concerns about dining service and staff behavior during care. During the January 2026 meeting, a grievance was filed regarding plastic silverware and paper plates, and later grievances were filed regarding cold food, dessert service, and staff using phones during care. The meeting notes and grievance records showed that the same issues continued to be brought forward by the Resident Council without documented resolution being communicated back to the residents in the council meetings. Resident #75 stated that the Resident Council met monthly, that the Activities Director and Activities Assistants recorded concerns, and that nothing was done about the concerns expressed during the meetings. She said she attended all Resident Council meetings and was frustrated by the lack of follow-up, especially regarding laundry and cold food. During the Resident Council interview, residents stated their concerns were not addressed and that they were told the issues were being reviewed, but nothing was ever done, making them feel like they did not make any difference.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from the wrongful use of their narcotic pain medications when oxycodone tablets were found missing for two residents. Resident #125 was admitted with lower lumbar radiculopathy and had an order for oxycodone 10 mg three times daily for lumbago/sciatic pain. The pharmacy delivered 90 tablets in three 30-tablet cards, and the delivery was signed for by Nurse #13. Later, the pharmacy denied an early refill request because 30 tablets should still have remained from the original delivery, but the tablets were not found. The facility’s review identified discrepancies in narcotic counts, including mathematical counting errors, lack of visual confirmation during counts, and missing signatures on end-of-shift count sheets. Resident #87 was admitted with chronic pain syndrome and had an active order for oxycodone 15 mg every four hours. The pharmacy delivered 180 tablets in six 30-tablet cards, signed for by Nurse #10. The facility later found that two cards, along with the corresponding declining count sheets, were missing from the medication cart. A second delivery of 180 tablets was also documented, and the facility’s investigation found only three of the six declining count sheets for that delivery. In total, three cards, or 90 tablets, were missing from the cart for Resident #87, and the missing medication cards and count sheets were never located. Interviews confirmed that the residents were receiving documented doses on the MARs and that neither resident reported unrelieved pain at the time. The DON stated the missing oxycodone was discovered after refill requests were denied as too soon, and that investigations were initiated after each event. Staff interviews described inconsistent narcotic count practices and missing documentation tied to the controlled substances. The facility stated the missing medication cards were never found, and the report notes that corrective actions could not be validated because a fully implemented corrective action plan was not provided.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its abuse policy and procedures for reporting, investigating, and protecting residents after an injury of unknown origin and after resident-to-resident abuse incidents. Resident #14, who had dementia with agitation and impaired memory, developed new swelling, pain, tenderness, and purplish discoloration of the left hand, wrist, and forearm on 4/1/26. Nursing staff documented that the source of the injury was unknown and that the resident could not verbalize what occurred. An x-ray obtained the next day showed acute fractures of the left radius and ulna, and the emergency department documented a closed left wrist fracture with no falls or injuries reported. The Administrator stated she had no information regarding the injury, had no incident report, and that the injury was not reported to the state agency, law enforcement, or APS. The DON also stated that no initial allegation report was submitted and no investigation was completed. The facility also failed to report and fully investigate two separate altercations between Resident #14 and Resident #110, both of whom resided in a special care unit and had severe cognitive impairment with wandering and behavioral symptoms. In one incident, Resident #110 was observed poking Resident #14 in the face, grabbing Resident #14's arm, attempting to bite, and biting staff while staff intervened; Resident #110 had reddened areas on the face and Resident #14 had bruising and a skin tear. In the second incident, staff heard arguing and found Resident #110 on the floor while Resident #14 was standing over her, holding her by the hair and kicking her in the face; Resident #110 had a knot on the back of her head and was sent to the emergency department. For both incidents, the facility completed internal reports, but there was no evidence that the reports were received by the state agency, and APS was not notified. The Administrator and Clinical Coordinator stated they were not aware of the APS reporting requirement, and one investigation report specifically noted that APS was not notified. The facility also failed to thoroughly investigate a reported abuse incident involving improper restraint use. An employee reported that two residents, Resident #3 and Resident #95, had gait belts placed around them and secured to their wheelchairs even though both residents were able to self-propel independently. The facility investigation timeline showed that the Activity Director reported the concern to the Administrator and DON, but the initial response relied on denials from the Clinical Coordinator and an RN, and a full investigation was not initiated until weeks later. The employee timecard showed that the Clinical Coordinator continued working full-time from the date of the incident until termination, and no protective measures were implemented during that period. The Administrator stated that a thorough investigation was not started when the allegation was first reported because staff denied it, and the required reporting to the state agency was delayed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to permit a resident to return after he was transferred to the hospital for a psychiatric evaluation related to aggressive behaviors toward other residents. The resident had diagnoses including generalized anxiety, Alzheimer's disease, dementia with behavioral disturbance, restlessness and agitation, recurrent moderate major depressive disorder, disorientation, and insomnia. His admission MDS showed severely impaired cognition, functional impairment, use of a walker and wheelchair, and need for supervision with all ADLs. During the resident's stay, staff documented repeated behavioral issues. He was found in another resident's room and was reported to have shaken that resident to wake her because he believed it was his room. The care plan identified behaviors directed toward others, wandering, disrobing, urinating and defecating in his room, packing belongings, and entering other residents' rooms. Interventions included 1:1 supervision, calm approaches, and redirection. Later, staff documented that he hit his roommate with a laminated piece of paper, and PRN lorazepam was given for agitation while he was on 1:1 observation. A psychiatry note recommended sending the resident to the hospital for a full psychological evaluation, with the hope that medications and nonpharmacological interventions could be adjusted after he returned. The resident was sent to the hospital by EMS for a psychiatric evaluation, and hospital records showed he was not admitted psychiatrically because the team did not feel he needed psychiatric admission; he was described as resting comfortably, pleasantly confused, and following commands. The hospital case manager documented that the facility was contacted and advised that it was unable to accept the resident back because of his aggressive behaviors, even though he was not exhibiting aggressive behavior at the hospital. The family then chose discharge to a community hospice house.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a safe environment free from accident hazards when a 2.75 oz can of WD-40 was observed in a resident’s room in a semi-private area that was easily accessible to other cognitively impaired residents. The resident was admitted with bilateral below-the-knee amputations, was cognitively intact, and used an electric wheelchair for mobility. During observation, the WD-40 was found on top of the dresser near the doorway entrance, and the resident stated he used it on his wheelchair as needed, had ordered it himself, and was unaware it should not be kept in the room where other residents could access it. Interviews confirmed that multiple residents on the unit wandered into other residents’ rooms and sometimes took belongings. The Clinical Coordinator, Social Worker, Nurse Aides, Nurse, Administrator, DON, and NP all stated that WD-40 should not be kept in a resident’s room because it was hazardous and could be accessed by cognitively impaired residents. The product label stated it was flammable, should be kept away from heat, sparks, and flames, and warned that inhalation of vapor or mist may be harmful or fatal.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to address psychiatric NP recommendations to increase trazodone for a resident with dementia, anxiety, restlessness, agitation, wandering, and nighttime sleep disturbance. The resident was admitted with diagnoses that included dementia, anxiety, restlessness, and agitation, and had a documented pattern of exit-seeking, wandering, refusing medications, and requiring 1:1 supervision. Trazodone had initially been ordered at 50 mg at bedtime, then reduced to 25 mg after a pharmacy recommendation for gradual dose reduction was accepted by the NP. After the dose was reduced, an NP progress note documented that staff reported increased anxiety and insomnia and that the resident had failed the dose reduction, but the order remained at 25 mg at bedtime. The record showed no new order to increase trazodone back to 50 mg at that time. Nursing notes later documented ongoing wandering throughout the night, the resident entering another resident’s room, being found in another resident’s bed, and becoming agitated and combative when redirected. The care plan continued to identify behavioral symptoms including restlessness, anxiety, agitation, wandering, and exit-seeking. A psychiatric assessment noted significant cognitive and behavioral challenges, agitation, suspicious behavior, and a history of violent behavior, and indicated medication management services were needed. A psychiatric follow-up later recommended increasing trazodone to 50 mg or 75 mg nightly for sleep and restlessness, but the MAR showed the resident continued to receive 25 mg nightly and no corresponding order was found. Interviews with the Clinical Coordinator, NP, Psychiatric NP, and DON confirmed that the psychiatric recommendation to increase trazodone was missed and not addressed, and the NP stated it was her error and that she thought the medication had been discontinued completely.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to label an opened insulin pen with the date it was opened and failed to discard expired medications stored on the 200-hall medication cart. During observation of the cart with Nurse #10, surveyors found one Insulin Glargine (Lantus) pen with no opened date even though it had been used, one bottle of Polyvinyl 1.4% ophthalmic solution with an open date of 3/4/26, and one house-stock bottle of Omeprazole that had been opened and used despite a manufacturer’s expiration date of April 2026. Review of the manufacturer’s guidelines showed that Lantus pens are to be discarded 28 days after opening and Polyvinyl 1.4% ophthalmic solution is to be discarded 90 days after opening. During interview, Nurse #10 stated nurses were required to check medication carts for expired medications and record the date insulin pens were opened, but she had not administered the Lantus, eye drops, or omeprazole that morning and had not noticed the expiration dates. The Administrator later stated all nurses were responsible for checking medication carts for expired medications and that insulin pens should be checked daily with opened dates recorded.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its infection control policy and procedures for Enhanced Barrier Precautions during wound care for a resident with a Stage IV pressure ulcer on the sacrum. During an observation, there was no Enhanced Barrier Precaution sign on the resident’s door and no PPE placed outside or at the entrance to the room. Nurse #9 and NA #7 were observed washing their hands and applying gloves, but they did not apply gowns before providing direct care activities related to the resident’s sacral wound. During the dressing change, NA #7 assisted the resident to roll onto her right side to expose the sacral area, and Nurse #9 removed the dirty sacral dressing. Nurse #9 was then observed not removing her dirty gloves and not sanitizing her hands before cleaning the wound with Normal Saline and applying calcium alginate with silver and a dry self-adhesive dressing. In interview, Nurse #9 stated she should have been wearing a gown and gloves during the dressing change and acknowledged she forgot to change gloves and sanitize her hands after removing the dirty dressing. The DON stated she was responsible for initiating EBP by placing the sign and PPE outside the resident’s door and confirmed she had missed doing so. NA #7 stated there was never a sign or PPE outside the room and that she should have been wearing a gown and gloves during wound care.

Penalty

Inspection fine: $55,172

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when staff failed to identify and mitigate an environmental hazard and provide adequate supervision for a newly admitted resident who was severely cognitively impaired and blind. The resident, who had a history of vascular dementia, frequent falls, and glaucoma, was placed in his wheelchair near a lit fireplace in the dining room after expressing that he felt cold. The nurse aide assigned to him left the resident unsupervised to assist another staff member, leaving the resident alone in close proximity to the hot fireplace. While unattended, the resident tipped his wheelchair backward, falling against the fireplace. His head, back, and shoulders came into contact with the hot mesh grate, resulting in second-degree burns with blistering to the back of his scalp, right shoulder, upper back, and left index finger, as well as a hematoma to the back of his head. The resident experienced severe pain, required emergency medical services, and was hospitalized for wound care and pain management. The incident was witnessed by another resident, who called for help, and staff responded after hearing the resident's cries. The facility lacked safety precautions to prevent residents from accessing or activating the fireplaces or coming into contact with the hot surfaces. There were no physical barriers, safety gates, or lockout features on the fireplaces, and staff had not received training or education regarding fireplace safety. The operational switches for the fireplaces were accessible to residents, and staff and residents were observed to regularly turn the fireplaces on and off. The environmental hazard was not recognized or addressed prior to the incident, and the resident was left unsupervised despite being identified as a high fall risk and having significant cognitive and visual impairments.

Removal Plan

• Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the lapse between the evening meal and breakfast the following day did not exceed 14 hours, as required. Observations and interviews revealed that meal carts for several areas were delivered for dinner as early as 4:30 PM and breakfast as late as 9:30 AM, resulting in time spans of 15 to 17 hours between meals. Staff interviews confirmed that breakfast was typically served between 8:15 AM and 9:30 AM, and the dinner meal was served as early as 4:30 PM, leading to extended periods without substantial food. Residents and staff reported that the long interval between dinner and breakfast left residents hungry in the morning. One resident specifically stated that the time between dinner and breakfast was too long and that she was very hungry by breakfast. Staff also noted that the facility no longer provided substantial evening snacks, such as sandwiches, and instead only offered small items like crackers or fruit cups if requested. The Director of Dining Services, Certified Dietary Manager, and Registered Dietitian all acknowledged that the current meal schedule did not meet the regulatory requirement of no more than 14 hours between the evening meal and breakfast, and that a nourishing snack should be provided if this interval is exceeded. The Compliance Coordinator indicated that the issue of meal timing had been discussed in Quality Assurance meetings, but no solution had been implemented to ensure compliance. The Registered Dietitian confirmed that the facility was not meeting the requirement to provide a nourishing snack when the interval between dinner and breakfast exceeded 14 hours. The lack of a process to ensure timely meal service and the discontinuation of substantial evening snacks contributed directly to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to address and communicate resolutions to grievances reported during Resident Council meetings for 10 out of 12 months reviewed. Review of Resident Council meeting minutes from April 2024 through March 2025 showed that concerns raised by residents, such as missed scheduled showers, staff using headphones or cell phones during care, delayed response to call lights, and issues with meal timeliness, were repeatedly documented without any follow-up or discussion of resolutions in subsequent meetings. The minutes consistently lacked documentation of how previous concerns were addressed, and residents reported that their ongoing issues were not being discussed or resolved at the start of each meeting. Interviews with residents confirmed that their concerns had persisted for months without resolution or feedback from facility staff. The newly hired Activities Director and the Administrator, both of whom started their roles recently, were unaware of how previous concerns had been managed and had no documentation to show that grievances were addressed. Residents continued to experience the same issues, including late breakfast service, unfulfilled shower schedules, delayed call light responses, and staff using headphones during care, indicating a pattern of unaddressed resident grievances over an extended period.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to coordinate and document a plan of care with the Hospice provider for two residents who had elected Hospice services. Both residents had significant cognitive impairments and multiple medical diagnoses, including dementia, malnutrition, and chronic pain. Although the residents' responsible parties had signed the Election of Hospice Benefit forms and Hospice care was indicated in their Minimum Data Set (MDS) assessments, the facility's care plans did not reflect that the residents were receiving Hospice services. Review of the electronic care plan records showed no current Hospice plan of care, only progress notes from Hospice. Interviews with the Director of Nursing (DON), MDS nurses, Clinical Compliance Administrator, and the Hospice Nurse confirmed that the facility's care plans were not updated to include Hospice interventions or documentation. The DON acknowledged that the process for obtaining and coordinating a Hospice care plan was not followed, and that the MDS nurses had overlooked updating the care plans. The Hospice Nurse stated that she provided all necessary documentation to the facility, but was unaware that the care plans had not been updated. Both the DON and Administrator confirmed that Hospice information should have been included in the facility's care plans for these residents, but it was not.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to transmit required Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) system within the mandated 14-day timeframe for four residents. Specifically, annual MDS assessments for three residents and a discharge MDS assessment for one resident were either marked as finalized or in production batch status, indicating that they were completed but not transmitted or not sent at all. These findings were based on record review and staff interviews, which confirmed that the assessments were not submitted as required. During an interview, the Director of Nursing (DON) explained that she was new to her position and that all MDS nurses were also new and still undergoing training. The DON acknowledged responsibility for managing and coordinating the assessments and stated that the delays in transmission were due to recent personnel changes in the MDS department. The DON clarified the status terms used in the system and confirmed that the assessments had not been transmitted within the regulatory timeframe.