Davis Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jun 23, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF689Oct 20, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Aug 9, 2022

  Based on record review and interviews with facility staff, Physician, Psychiatric Physician's Assistant (Psych PA), and observations, the facility failed to protect a resident with severe cognitive impairment from a hazardous environment when a resident wrapped a call light cord around her neck and tied the cord in a knot on three separate occasions (04/29/22, 07/12/22 and 07/22/22) for 1 of 7 residents reviewed for accidents (Resident #11). This deficient practice placed Resident #11 at risk for asphyxiation (deprivation of oxygen) which can result in loss of consciousness, [CONDITION(S)], or death. Immediate Jeopardy began on 7/12/22 when Resident #11 was observed with the call bell cord wrapped loosely around her neck and tied in a knot. […]

• Immediate jeopardy, isolatedF600Jun 21, 2021

  Based on staff interviews, physician interview and record review the facility neglected to identify the urgency for the need for medical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] #240). Resident #240 was sent to the hospital for evaluation at approximately 8:20 AM on [DATE] by the on-coming shift. He expired the next day ([DATE]) at the hospital with discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Immediate Jeopardy began on [DATE] when Resident #240 experienced falls with a head injury at 2:45 AM and again at 6:00 AM and the facility neglected to initiate immediate medical attention. 911 was not called until 7:54 AM. Immediate Jeopardy was removed on [DATE] when the facility provided and implemented an acceptable plan of Immediate Jeopardy removal. […]

• Actual harm, isolatedF604Jun 23, 2026

  Based 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. […]