South Davis Specialty Care

In the surveyor’s words

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

• Actual harm, isolatedF684Dec 6, 2021

  Based on interview and record review it was determined, for 1 out of 31 sampled residents, that the facility did not ensure that the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . This was cited at a harm. Resident identifier 25. Findings included: Resident 25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/29/21 at 2:36 PM, an interview was conducted with resident 25. Resident 25 stated that his shoulder was fractured during range of motion (ROM) exercises that was provided by Restorative Nurse Aide (RNA) 1. […]

• No harm, potential for more than minimal, patternF812Dec 11, 2025

  Based on observation, interview, and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the food was not served in a sanitary manner. Findings included: On 12/10/25, during the tray line of lunch service the following was observed:a. At 12:04 PM, the cook was observed to don gloves and was then observed to pick up a packet of papers and flip through them with gloved hands. The cook was then observed to pick up 2 breadsticks with the dirty gloved right hand and then placed the breadsticks on the resident's plate. b. At 12:06 PM, the Dietary Aide (DA) was observed to don gloves and was then observed to touch a kitchen exit door, the door to the food cart, and the aluminum foil box. […]

• No harm, potential for more than minimal, patternF812Nov 8, 2023

  Based on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, multiple food items were open to air, not dated and not labeled in the kitchen. Findings include: 1. During an initial walk-through of the kitchen on 11/6/23 at 9:07 AM the following was observed. a. Plastic clear container of frozen peas did not have a date or label. 2. During the follow-up visit to the kitchen on 11/8/23 at 11:40 AM the following was observed. a. Multiple sheets of uncooked bacon in the refrigerator was not dated or labeled and the food was not covered. b. Salad in plastic container with tomatoes and lettuce in the refrigerator was not dated or labeled. c. […]

• No harm, potential for more than minimal, patternF880Dec 6, 2021

  Based on observation, interview and record review it was determined that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, visitors were not screened upon entrance to the facility, a laundry services staff member was observed to not perform hand hygiene between resident rooms, a staff member was observed in a resident care area without personal protective equipment (PPE), and the blood glucometer machine was not sanitized according to manufacturer requirements. Findings Include: 1. On 12/1/21 at 7:00 AM, the state agency surveyor entered the facility. […]

• No harm, potential for more than minimal, isolatedF693Dec 11, 2025

  Based on observation, interview, and record review, it was determined, for 1 out of 27 sampled residents, the facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. Specifically, one resident was observed to have their head of bed lower than 30 degrees when the tube feeding was being administered. Resident identifier: 8. […]