South Davis Specialty Care

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. The DA was then observed to pick up a bowl using the pinching method with her thumb on the outside of the bowl and her pointer and middle finger on the inside of the bowl. The DA was then observed to give the bowl to the cook who filled it with soup and placed it on a resident's lunch tray.c. At 12:07…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Findings included:Resident 8 was admitted to the facility on [DATE] with diagnoses which included spastic quadriplegic cerebral palsy, acute and chronic respiratory failure, Familial Dysautonomia, epileptic spasms, dysphagia, gastrostomy, and gastro-esophageal reflux. On 12/8/25 at 11:10 AM, an observation was made of resident 8 laying in her crib with her head of the bed elevated to what appeared to be 10 degrees. Her tube feeding was observed to be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, it was determined for 1 out 27 sampled residents, the facility failed to ensure that in the resident's clinical record laboratory (lab) reports that were dated and contain the name and address of the testing laboratory. Specifically, one resident was missing lab reports in their medical record. Resident Identifier: 25 Findings Included: Resident 25 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia.Review of resident 25's medical record was completed on 12/8/25 through 12/11/25.On 4/17/25, a physician's order for Basic Metabolic Panel (BMP) one time only for pulmonary was marked completed.It should be noted that the lab result for the BMP on 4/17/25, was unable to be located in the medical record.On 4/17/25, a physician's order for Arterial Blood Gas (ABG) one time only for Carbon Dioxide. An ABG to be obtained for Pulmonologist to be cleared for surgery, was marked completed.It should be noted that the lab result…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, it was determined for 2 out 27 sampled residents, the facility failed to ensure that each resident's medical record was accurately documented and maintained. Specifically, a resident's medical document was located in another resident's medical record. Resident Identifier: 25 and 64.Findings Included: A review of resident 25's medical record was conducted. During the review it had revealed that resident 64's urinalysis with culture and sensitivity with a date of service of 4/15/25, was located in resident 25's medical record.On 12/11/25 at 11:16 am, an interview was conducted with the Medical Records Lead (MRL). The MRL stated every morning the medical records were collected from the nurses' stations at which time they were sorted by name and the date of services. The MRL stated before the scan was uploaded to the resident's medical record it was verified that the name on the document matched the name on the file. The MRL stated that around April 2025, they had a temporary remote person that was helping. The MRL stated that he should have been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. Mixed salad in a large plastic tray with plastic wrap over it was not dated or labeled. d. Coconut pie was observed thawing in the walk in refrigerator. The label stated to thaw whole sliced pie 8 hours or over night in fridge. There was no date when the pie was pulled from freezer. e. A container of frozen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 staff were present at the entrance, and screening was not conducted of the state agency surveyors. An N95 mask and eye protection was donned by the surveyor and entrance was obtained to the 2nd floor resident care area. Shift change was in progress and occurred at 7:00…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 31 sample residents, that the facility did not immediately consult with the resident's physician when there was an accident involving the resident which resulted in an injury and had the potential for requiring the physician's intervention. Specifically, a resident sustained a fracture during Passive Range of Motion (PROM) exercises and the physician was not notified for two days following the incident. Resident identifier 25. Findings included: Resident 25 was admitted to the facility on [DATE] with diagnoses which included quadriplegia Cervical (C)1-C4 complete, Pressure Ulcer (PU) right heel stage 3, PU left elbow stage 2, PU right elbow stage 2, muscle spasms, insomnia, functional dyspepsia, pain, tracheostomy, chronic respiratory failure, adjustment disorder with mixed anxiety and depressed mood. 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)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 31 sample residents, that the facility did not ensure that residents who used psychotropic drugs received a gradual dose reduction (GDR) unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, a resident received an anti-anxiety medication for approximately 21 months without an attempted GDR or a physician documented rationale for why any attempted dose reduction would likely impair the resident's function or exacerbate an underlying medical or psychiatric disorder. Resident identifier 28. Findings included: Resident 28 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure, morbid obesity, major depressive disorder, tracheostomy, type 2 diabetes mellitus, anxiety disorder, metabolic encephalopathy, hypertension, and chronic pain. On 12/6/21 resident 28's medical records were reviewed. Review of resident 28's physician orders revealed an order for Alprazolam 0.5 milligram…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.