University Retirement Community at Davis

In the surveyor’s words

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

• Actual harm, isolatedF689Oct 25, 2024

  Based on observation, interview, and record review, the facility failed to provide a safe environment with adequate supervision for one of three sampled residents (Resident 1), when Resident 1 eloped (left facility unsupervised and without prior authorization) from facility, fell , and then was moved after the fall before being assessed by a licensed nurse (LN). This failure resulted in Resident 1 experiencing a left orbital fracture (fracture of the bones of the eye socket) and contusion (bruise) of right lower leg and had the potential for further injury. […]

• No harm, potential for more than minimal, widespreadF812Dec 9, 2022

  Based on observation, interview, and record review, the facility failed to identify and prevent hazards at specific points of food handling for total of 25 residents when: 1. Staff did not wear a beard net while handling food; and 2. A can opener was found with rust and in use. These failures had the potential to place residents at risk for foodborne illnesses. Findings: During an observation of meal preparation on 12/6/22, at 9:40 a.m., Food Server (FS) 1 was observed to be wearing a face mask and to have a beard without wearing a beard cover. The face mask failed to restrain all of the beard. […]

• No harm, potential for more than minimal, patternF761Sep 19, 2025

  Based on observation, interview, and record review, the facility failed to maintain a safe and secure storage of medications for two of 17 sampled residents (Resident 8 and Resident 20), for a census of 36 when:1a.Resident 8's unlabeled medication was left at bedside;1b.Resident 8's discontinued controlled medications were stored in the medication cart;2. Resident 20's expired medication was stored in the medication room; and,3. Two bottles of expired vitamins were stored in the medication room.These failures increased the potential for medications to be accessible to other residents, increased the potential for drug diversion, and administration of vitamins with decreased effectiveness. Findings: 1a. […]

• No harm, potential for more than minimal, patternF812Sep 19, 2025

  Based on observation, interview and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety for a census of 36 when: 1.Food items in the refrigerator were observed to be uncovered; and,2. Potentially hazardous food (food that requires time/temperature control for safety to limit the growth of organisms capable of causing a disease) had inaccurate labeling.These failures had the potential to result in foodborne illnesses. Findings: During a concurrent observation and interview, on 9/16/2025 at 8:18 a.m. of the walk-in refrigerator #8, with the Nutritional Services Supervisor (NSS), a large plastic bin of dark orange sauce was observed on the refrigerator shelf uncovered. […]

• No harm, potential for more than minimal, patternF880Sep 19, 2025

  Based on observation, interview, and record review, the facility failed to maintain and follow an effective infection prevention and control program for a census of 36 when:1.Resident 40's CPAP (continuous positive airway pressure- ensures uninterrupted breathing and oxygen) mask and distilled water used for the treatment were not properly stored;2. Staff did not consistently follow transmission-based precautions (TBP) for Resident 37;3. Resident 20's distilled water used for CPAP treatment was observed unlabeled and on the floor; 4. Dirty linens were observed on the floor of the laundry room; and5. The facility management was not informed of positive Legionella (a type of bacteria found in [NAME] that can cause a serious type of lung infection) testing results. […]