Davis and McDaniel Veterans Care Center

In the surveyor’s words

From the most serious findings on record at Davis and McDaniel Veterans Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF628Jan 8, 2026

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to notify the Office of the Long-term Care Ombudsman of resident transfers and/or discharges to higher levels of care and the facility staff failed to ensure the appropriate information was provided to the receiving healthcare institution(s) and/or resident(s) and resident representative(s) for 2 of 35 residents, Residents #6 and #125. The findings included:1.For the facility, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman of resident transfers/discharges to higher levels of care. This surveyor requested evidence that the Office of the State Long-Term Care Ombudsman received notification of resident transfers/discharges to higher levels of care. […]

• No harm, potential for more than minimal, isolatedF657Jan 8, 2026

  Based on staff interview and clinical record review, the facility staff failed to review and revise the residents comprehensive care plan (CCP) to include the residents current code status for 1 of 35 current residents, Resident #9.The findings included:The facility staff failed to include Resident #9's code status on their CCP when the care plan was reviewed and revised on 12/05/25. Resident #9's diagnoses included myocardial infarction, peripheral vascular disease, and post-traumatic stress disorder.Section C (cognitive patterns) of Resident #9's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/24/25 included a brief interview for mental status (BIMS) score of 14 out of a possible 15 points indicating Resident #9 was cognitively intact.Resident… […]

• No harm, potential for more than minimal, isolatedF684Jan 8, 2026

  Based on staff interview, resident interview, clinical record review and facility document review, the facility staff failed to follow physician orders for 1 of 35 current residents, Resident #1. The findings included:For Resident #1 the facility staff failed to follow physician's orders for sliding scale insulin protocol.Resident #1's clinical record listed diagnoses which included but not limited to type 2 diabetes mellitus and chronic kidney disease.Resident #1's most recent minimum data set with an assessment reference date of 10/15/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. […]

• No harm, potential for more than minimal, isolatedF684Jan 27, 2022

  Based on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to administer the physician ordered vitamin [MEDICATION(S)] senior for 1 of 33 residents, Resident #44. The findings included: For Resident #44, the facility staff failed to administer the physician ordered vitamin [MEDICATION(S)] senior per the physicians order. Resident #44's clinical record included the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #44's annual MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/17/21 included a BIMS (brief interview for mental status) summary score of 3 of 15. […]