Health inspection·March 20, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated, [Resident 1] is a 98yr [year] old female who present to [hospital name] on 3/5/25 for: right femoral neck [hip] fracture after falling at SNF [skilled nursing facility] on 3/4/25. During a concurrent observation and interview on 3/12/25 at 10:33 a.m., Resident 1 sat in a wheelchair, alert and verbally responsive at the bedside with family member present. Resident 1 stated, My leg still trying to get it back together. When asked about the fall, the resident stated, I don ' t remember falling. I ' m getting confused with the time, you know, between our time and your time, and the [NAME] time. I guess the time changed. When asked if the fall was the first time for the resident, the resident stated, All the time. I don't think I have any proof of it. During an interview on 3/12/25 at 10:35 a.m. with Family Member 1 (FM 1), FM 1 stated, [Resident 1] had a fall four years ago at home. She broke her left hip, and this time that she fell on that bathroom, her right hip .She cannot be left alone .she's forgetful and she's a confused. During an interview on 3/12/25 at 10:38 a.m. with Resident 1 and FM 1, when asked what the year was, Resident 1 stated, Right now, yes. This year will be my 100th birthday. Right now, what year? Let me see if I have that right. Resident 1 could not recall the current year. When asked if the resident can go to the bathroom, the resident stated, I don ' t think that's fine. I need help .I go in, but I have to have somebody nearby . FM 1 stated, [Resident 1] cannot be left alone in the bathroom. She needs a lot of supervision. She is not able to stand up in the bathroom. During an interview on 3/12/25 at 10:45 a.m. with FM 1, FM 1 stated, My concern regarding the fall, I would prefer that even when [Resident 1] is in the bathroom that I don't care about privacy. I think it's more important to keep eyes open for her safety. I think there's a way to do that without closing the door .I think it's just to look there and supervise her all the time because of her confusion. She is going to be [AGE] years old in April, and I would prefer as always because we don ' t know if she's not going to necessarily know not to get up or trying to get up on her own. During an interview on 3/12/25 at 11:05 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated, [Resident 1] has dementia and she needs to be supervised for safety .If she is on the toilet, you're not supposed to leave or close the door or anything like that .when they are confused . During an interview on 3/12/25 at 11:08 a.m. with Licensed Nurse 1 (LN 1), LN 1 stated, [Resident 1] had a fall on the 4th [March, 2025]. [Resident 1] was unsupervised, and to be left at the bathroom, none of that should have happened. She is forgetful and confused .she has cognitive problems. During an interview on 3/12/25 at 11:18 a.m. with the Occupational Therapist (OT), the OT stated, [Resident 1] needs a lot of supervision in terms of activities of daily living .She is not safe being left alone. During an interview on 3/12/25 at 11:22 a.m. with the Social Services Coordinator (SSC), the SSC stated, [Resident 1] needs a lot of supervision. When asked if the resident was safe to be left alone in the bathroom, the SCC stated, I would say no, absolutely not. During an interview on 3/12/25 at 11:30 a.m. with the Activities Director (AD), the AD stated, Definitely, [Resident 1] has some confusion .I wouldn't say she would be safe going to the bathroom by herself. I think she definitely needed assistance with any activity, all the time. During an interview on 3/12/25 at 11:52 a.m. with the Physical Therapy Rehab Director (PTRD), the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555769 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555769 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE University Retirement Community at Davis 1515 Shasta Drive Davis, CA 95616 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few PTRD stated, [Resident 1] needed help all the time. She is not safe to be alone in the bathroom to do her activities or take a shower or toileting .She needed supervision every time with her toileting .somebody should be with her because of her mentation, and her aides usually stay with her for safety. During an interview on 3/12/25 at 12:31 p.m. with the MDS Coordinator (MDSC), the MDSC stated, [Resident 1] was confused at times and forgetful. She needed a lot of help and supervision .I don't think that she was safe being alone in the bathroom because of her confusion. During an interview on 3/12/25 at 2:15 p.m. with the Director of Nursing (DON), the DON stated, The CNAs should not leave their residents alone in the bathroom when they are confused. They should always be there when they are assisting the resident . During an interview on 3/12/25 at 1:55 a.m. with the Administrator (ADM), the ADM stated, I know that our staff are big into like respecting the residents ' wishes, but in this case, [Resident 1] is not oriented. She has dementia. [CNA 1] should have taken that into consideration. During a telephone interview on 3/13/25 at 9:28 a.m. with CNA 1, CNA 1 indicated she brought Resident 1 by wheelchair, assisted and transferred her to the toilet, and stated, I left the bathroom to give her privacy. CNA 1 stated, I heard the fall through the cracked door while waiting for her to use the call light. During a review of the facility ' s policy and procedure (P&P) titled Fall Reduction and Management Program Policy and Procedure, dated 10/2023, the P&P indicated, Evaluation should consider supervision that may be needed based on the individual resident ' s needs and risks. Considerations of special needs may include, but not limited to: a. Residents with cognitive impairment. b. Residents with recurrent falls. c. Toileting supervision: Whether resident needs direct supervision in the bathroom or whether resident can use bathroom call light independently and appropriately and staff can remain directly outside the bathroom if resident requests. d. unsafe behaviors. During a review of the facility ' s P&P titled Safe Environment/Accident P&P, the P&P indicated, All reasonable precautions will be taken by the facility to protect a resident from possible injury from dangerous conditions, falling . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555769 If continuation sheet Page 3 of 3