Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at University Retirement Community At Davis during CMS and state inspections, most recent first.
A resident with a history of cognitive impairment and high fall risk was left unsupervised in the bathroom, leading to a fall and right hip fracture. Despite clear care plans and facility policies requiring supervision, a CNA left the resident alone for privacy, resulting in the incident. Staff interviews confirmed the resident's need for constant supervision due to confusion and memory issues.
A resident with severe cognitive impairment and a history of wandering eloped from the facility, resulting in a fall and injuries, including a left orbital fracture. The incident occurred during a short-staffed night shift, and the resident's wander guard was not in place. Staff failed to follow protocol by moving the resident before a nurse's assessment, and there was inadequate monitoring of the wander guard's functionality.
The facility failed to provide safe and accurate pharmaceutical services for four residents. A resident did not receive their prescribed medication due to unavailability, while another's bladder treatment was not administered as ordered. Additionally, there was a lack of accurate accountability for controlled medications for two residents, with discrepancies in documentation and disposal. The DON confirmed these issues, highlighting failures in medication administration and record-keeping procedures.
The facility failed to properly store and label medications and supplies, including Gabapentin left on a countertop, an unlabeled bottle of sterile water with Gentamicin, and incomplete room temperature logs. Discontinued medications were stored in a retrievable form, and expired supplies were found mixed with others. An unlabeled bottle of mineral oil was also discovered in the medication cart. These issues increased the risk of unsafe medication administration and potential diversion.
The facility failed to follow recipes and portion sizes during meal preparation, specifically with Beef Fajitas. The Lead Cook did not measure ingredients or follow the recipe, and the Lead Nutritional Aide used incorrect scoop sizes and omitted cheese. The Corporate Registered Dietitian confirmed the importance of following recipes and portion sizes to ensure proper nutrition for residents. The Executive Chef acknowledged the absence of a guide for scoop sizes, contributing to the issue.
The facility failed to maintain food safety standards, with unlabeled and expired food items found during a kitchen tour. Cleaning protocols were not followed, leading to powder accumulations and improper storage of utensils. Badly scraped cutting boards were used, and a dietary aide did not wear a beard net. Expired cranberry juice was served to residents, increasing the risk of foodborne illnesses.
The facility failed to develop comprehensive care plans for two residents, leading to potential unmet needs. One resident on anticoagulants had no care plan for monitoring bleeding, resulting in undocumented bruising. Another resident experienced a fall with injuries, but no care plan or monitoring was documented. The DON confirmed these deficiencies.
A resident with Type 2 Diabetes Mellitus experienced episodes of hypoglycemia, but the attending physician was not notified as required by the care plan and physician's order. The MAR indicated two instances of low blood sugar, yet there was no documentation of physician notification or interventions. Interviews with staff confirmed the oversight, and the DON acknowledged the failure to follow the doctor's order.
Resident Left Unsupervised in Bathroom Resulting in Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision for a resident, leading to a fall and subsequent injury. The resident, who was admitted with a history of left hip fracture, delirium, and confusion, was identified as high risk for falls. Despite this, the resident was left unattended in the bathroom during toileting, which resulted in a fall and a right hip fracture. The resident's care plan and fall risk evaluation clearly indicated the need for supervision due to severe memory impairment and dependency on assistance for activities of daily living. Interviews with various staff members, including a CNA, licensed nurse, occupational therapist, and the Director of Nursing, confirmed that the resident required constant supervision, especially during toileting, due to cognitive impairments and confusion. The CNA responsible for the resident admitted to leaving the resident alone in the bathroom to provide privacy, which was against the facility's policy and the resident's care requirements. The fall was not witnessed, but the CNA heard the fall through a cracked door while waiting for the resident to use the call light. The facility's policies on fall reduction and safe environment emphasize the need for supervision based on individual resident needs, particularly for those with cognitive impairments and recurrent falls. The failure to adhere to these policies and provide necessary supervision directly contributed to the resident's fall and injury. Interviews with family members and staff highlighted the resident's need for supervision and the importance of prioritizing safety over privacy in such cases.
Resident Elopement and Injury Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide a safe environment and adequate supervision for a resident who eloped from the facility, resulting in a fall and subsequent injuries. The resident, who had severe cognitive impairment and a history of wandering, was found outside the facility with a left orbital fracture and a contusion on the right lower leg. The resident had previously been identified as high risk for wandering and had orders for a wander guard, which was not in place at the time of the incident. The incident occurred during a night shift when the facility was short-staffed, with only two CNAs on duty instead of the usual three. The CNAs were unable to monitor all residents effectively, and the resident was last seen in bed at approximately 3:00 a.m. before being found outside around 5:00 a.m. The CNAs did not follow protocol by moving the resident before a licensed nurse could assess her, which was against the facility's policy. Interviews with staff revealed that the resident frequently removed her wander guard, and there was no consistent monitoring of the device's placement and functionality prior to the incident. The facility's policies on elopement, fall management, and wander guard usage were not adequately followed, contributing to the resident's elopement and subsequent injuries.
Pharmaceutical Service Deficiencies in Medication Administration and Record Keeping
Penalty
Summary
The facility failed to ensure the safe and accurate provision of pharmaceutical services for four residents. Resident 89 did not receive their prescribed medication, Oxybutynin, as it was not available during the scheduled administration time. The Licensed Nurse (LN) responsible for administering the medication stated that the medication was ordered from the pharmacy the day before, but it was not available in the medication cart. The Director of Nursing (DON) indicated that medications should be reordered nine days before they run out, which was not adhered to in this case. Resident 5's prescribed bladder treatment was not followed as ordered. The physician's order required the use of Gentamicin mixed with 250 ml of normal saline, but instead, a 500 ml bottle of sterile water was used. The Resident Care Manager (RCM) confirmed that the solution used did not have the resident's name or the correct amount of Gentamicin indicated. The DON acknowledged that the solution was not properly labeled and that the physician's order was not followed. For Residents 23 and 31, there was a lack of accurate accountability for controlled medications. Resident 23's Controlled Drug Record (CDR) indicated that Oxycodone was signed out, but the Medication Administration Record (MAR) did not show it was administered. Similarly, for Resident 31, Tramadol was signed out but not documented as administered, and there was no evidence of its disposal. The DON confirmed these discrepancies and stated that controlled medications should be documented in both the CDR and MAR, and if refused, should be wasted with another nurse present.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and supplies, as observed during a survey. A medication container labeled Gabapentin was found on the countertop in the medication room, which was confirmed by the Resident Care Manager (RCM) to have been removed from the automated medication dispensing machine (ADM) and left there until pharmacy pickup. The Director of Nursing (DON) acknowledged the need for a designated area to store such containers. Additionally, an opened bottle of sterile water mixed with Gentamicin was found in the refrigerator without a resident's name, which was used for a resident's suprapubic catheter flush. The DON admitted the solution was not properly labeled. The facility also failed to maintain complete documentation of room temperature in the medication room, with several days missing from the log. The RCM confirmed the log was supposed to be completed by the morning shift, and the DON expected daily checks and logging. Furthermore, discontinued non-controlled medications were stored in a retrievable form, with loose pills and creams found in a container that was not locked. The RCM and DON both acknowledged the potential for these medications to be diverted and the need for proper disposal methods. Expired supplies, including needleless connectors, were found mixed with other supplies in the medication room, posing a risk for infection. The RCM stated that everyone was responsible for ensuring no expired supplies were present. Additionally, an opened bottle of mineral oil was found in the medication cart without a resident's name or date, and the DON confirmed the lack of labeling and was unaware of its intended use. These deficiencies highlight the facility's failure to adhere to professional standards for medication storage and labeling, increasing the risk of unsafe administration and potential medication diversion.
Failure to Follow Recipe and Portion Sizes in Meal Preparation
Penalty
Summary
The facility failed to ensure that recipes were used and followed during meal preparation, specifically when preparing Beef Fajitas. During an observation, the Lead Cook (LC) was seen preparing Beef Fajitas without measuring the ingredients as per the recipe. The LC was unable to specify the amount of beef and vegetables used and added unmeasured amounts of seasoning, which was not listed in the recipe. The Corporate Registered Dietitian (CRD) confirmed that the staff is expected to follow the recipe for the number of portions and seasoning. Additionally, the facility did not adhere to the specified portion sizes when serving the Beef Fajitas. The Lead Nutritional Aide (LNA) used incorrect scoop sizes for the beef, tomatoes, and lettuce, and omitted cheese, which was part of the recipe. The CRD emphasized the importance of using the correct utensils and serving sizes to ensure residents receive the necessary nutrition. The Executive Chef admitted that there was no guide for scoop sizes posted in the kitchen or dining room. The facility's policies on dietary services and cycle menu production were not followed, as evidenced by the lack of adherence to recipe instructions and portion sizes. The absence of a posted guide for disher sizes contributed to the staff's inability to serve meals according to the established standards. This failure had the potential to alter the nutritional value of the meals and affect the health status of the 36 residents receiving food from the kitchen.
Food Safety and Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by multiple deficiencies observed during a kitchen tour. Opened food products, including milk, heavy whipping cream, garlic naan bread, and various condiments, were found unlabeled in the refrigerator and dry storage areas. This lack of labeling was confirmed by the Lead and acknowledged by the Corporate Registered Dietitian, who stated that all opened food items should be labeled to ensure proper tracking and disposal. Additionally, several food items were found past their best-by dates, including liquid egg yolks, chili pepper sauce, and various cakes, which were not discarded as required by facility policy. The facility also exhibited poor cleanliness and organization in its food storage areas. White and grayish powder accumulations were found on the lids of several food storage bins, and an unknown liquid was present on the lid of a couscous bin. Onion peels were observed on the floor of the dry storage room, and a steak knife was improperly stored on top of a quinoa box. These observations were verified by the Lead, who admitted that cleaning protocols were not being followed. The Corporate Registered Dietitian emphasized the importance of adhering to cleaning schedules to prevent contamination. Additional deficiencies included the use of badly scraped cutting boards, which were still in use despite being difficult to clean and sanitize effectively. A dietary aide was observed not wearing a beard net while preparing food, contrary to facility policy and FDA guidelines. Furthermore, a pitcher of cranberry juice was served to residents past its labeled consume-by date, with staff admitting to changing labels instead of discarding expired items. These actions and inactions collectively increased the risk of foodborne illnesses for the residents receiving food from the facility's kitchen.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to potential unmet needs. Resident 9, diagnosed with unspecified dementia and atherosclerotic heart disease, was prescribed Xarelto, an anticoagulant, but had no care plan addressing the use of this medication. Despite orders to monitor for signs of bleeding, such as increased bruising, there was no documentation of monitoring from June 1 to June 11, 2024. On June 11, 2024, Resident 9 was observed with bruises on his arms, which were not previously reported or documented. The Director of Nursing confirmed the absence of a care plan for anticoagulant use and the lack of documentation regarding the bruising. Resident 18, with a diagnosis of unspecified atrial fibrillation, experienced a fall on May 27, 2024, resulting in skin tears. Although there was a care plan for high fall risk, no care plan was initiated for the actual fall or the resulting injuries. On June 11, 2024, Resident 18 was observed with steri-strips and a dry dressing on her injuries, but there was no care plan or monitoring documented for these injuries. The Director of Nursing confirmed the lack of a care plan for the fall and the skin tears, stating that the licensed nurse should have completed the care plan and obtained treatment orders.
Failure to Notify Physician of Hypoglycemia Episodes
Penalty
Summary
The facility failed to maintain professional standards of quality for a resident with Type 2 Diabetes Mellitus by not notifying the attending physician of episodes of hypoglycemia as ordered. The resident's care plan, revised in March 2024, indicated the need to monitor, document, and report signs and symptoms of hypoglycemia. A physician's order from May 2024 specified that the doctor should be notified if the resident's blood sugar fell below 80 mg/dl. However, the Medication Administration Record (MAR) for June 2024 showed two instances where the resident's blood sugar was recorded at 74 mg/dl, but there was no documentation of physician notification or interventions for these episodes. Interviews with facility staff, including a Licensed Nurse and the Director of Nursing (DON), confirmed that the physician was not notified as required by the order. The DON verified the lack of documentation regarding physician notification and acknowledged that the failure to follow the doctor's order could prevent the doctor from ordering necessary treatments. The facility's policy on medication and treatment administration, as well as the Nursing Practice Act Rules and Regulations, emphasize the importance of administering medications as prescribed and reporting observed abnormalities, which were not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Davis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Courtyard Health Care Center | 2.2 mi | — | 6 | 0 |
| Woodland Post-acute | 7.7 mi | — | 24 | 0 |
| Cottonwood Healthcare Center | 7.8 mi | — | 0 | 0 |
| The Grove Post-acute | 8.3 mi | — | 2 | 0 |
| River Bend Nursing Center | 12.5 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.