Davis Place

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Apr 16, 2025

  Based on review of clinical records, interviews, facility documentation and facility policy for one (1) of three (3) residents (Resident #3) reviewed for medication errors, the facility failed to prevent a significant medication error by failing to accurately transcribe and verify Provider's orders for a resident readmitted to the facility. This failure resulted in the finding of Immediate Jeopardy. The findings include: Resident #3 received 30,000 mg of Hydroxyurea in excess from the hospital order which resulted in a hospitalization due to critical lab values (lab value date range: 3/14/25 through 3/28/25) which identified decreasing white blood cell (WBC) values from 12.62 to 0.99 (normal range 4.5 to 11) and decreasing platelet values from 962 to 129 (normal range 150 to 450). […]

• Actual harm, isolatedF689Sep 9, 2025

  Based on observations, review of clinical records, facility documentation, facility policy, and interviews for one of three residents (Resident #1) reviewed for accidents, staff failed to move the food service cart in a safe manner to ensure no residents were in the path. The failure resulted in a resident fall with injury. The findings include: Resident #1's diagnoses included dementia, glaucoma, and schizoaffective disorder. The Resident Care Plan (RCP) dated 6/11/2025 identified Resident #1 ambulated independently with a cane. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of six out of fifteen, indicative of severe cognitive impairment, and required supervision with ambulation. […]

• Actual harm, isolatedF689Jun 16, 2025

  Based on review of the clinical record, facility documentation, facility policy, and interviews, for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to ensure wheelchair footrests were in place to support a safe transfer. Resident #1, who was severely cognitively impaired, was directed by staff to lift his/her feet during the transfer; subsequently, the resident fell from the wheelchair and sustained multiple fractures. The findings include: Resident #1 's diagnoses included dementia with behavioral disturbances, mood disorder and muscle weakness. […]

• No harm, potential for more than minimal, patternF812Jul 6, 2026

  Based on observations, interviews, and policy review, the facility failed to ensure exposed hair was restrained during food preparation and service and failed to ensure food contained in a Styrofoam container was not reheated in the microwave. The finding include: 1. Observation and interview on 7/1/26 at 11:52 AM identified [NAME] #1 preparing to plate resident food by the steam table in the kitchen. [NAME] #1 was wearing a baseball cap and his hair was hanging freely down to his shoulders without a hair restraint. [NAME] #1 indicated that the facilities policy was that staff wearing baseball caps did not need to wear a hair restraint even if their hair was not contained outside of the cap. […]

• No harm, potential for more than minimal, patternF656Apr 16, 2025

  Based on review of clinical records, interviews, facility documentation and facility policy for two (2) of three (3) residents (Resident #2 and Resident #3) reviewed for Resident Care Plans (RCPs), the facility failed to update comprehensive RCPs to address the residents needs. The findings included: 1. Resident #2 was admitted to the facility in March of 2025 with diagnoses that included periprosthetic fracture around internal prosthetic left knee joint, pain in the left knee, and depression. […]