Cycle 1
Health 2025-09-19 · Fire 2025-09-19
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Davis, CA
University Retirement Community At Davis
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1515 Shasta Drive, Davis, CA
(530) 747-7000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
37
Certified beds
Average residents
34
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Pacific Retirement Services
Operator or chain grouping
Approved since
2001-04-16
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
10 facilities
Chain averages 5 overall / 4 health / 4 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.64
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.24
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.83
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.71
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.88
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.24
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
1.22
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.25
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.76
CMS adjusted RN staffing hours
Adjusted total hours
5.05
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
541
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
68.02
Composite VBP score used to determine payment impact.
Payment multiplier
1.0213
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.01
Baseline 20.91% · Performance 18.18% · Measure score 7.01 · Achievement 7.01 · Improvement 6.53
Healthcare-associated infections
6.59
Baseline 5.53% · Performance 5.86% · Measure score 6.59 · Achievement 6.59 · Improvement 0
Total nurse turnover
7.80
Baseline 33.33% · Performance 31.82% · Measure score 7.80 · Achievement 7.80 · Improvement 1.29
Adjusted total nurse staffing
5.81
Baseline 5.87 hours · Performance 4.73 hours · Measure score 5.81 · Achievement 5.81 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.02% |
10.72%
2.7 pts better
|
No Different than the National Rate · Eligible stays 131 · Observed rate 1.53% · Lower 95% interval 5.11% |
| Discharge to community | 70.35% |
50.57%
19.8 pts better
|
Better than the National Rate · Eligible stays 126 · Observed rate 72.22% · Lower 95% interval 62.17% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.86% |
95.27%
3.6 pts better
|
Numerator 87 · Denominator 88 |
| Falls with major injury | 1.14% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 88 |
| Discharge self-care score | 72.22% |
53.69%
18.5 pts better
|
Numerator 52 · Denominator 72 |
| Discharge mobility score | 70.83% |
50.94%
19.9 pts better
|
Numerator 51 · Denominator 72 |
| Pressure ulcers or injuries, new or worsened | 3.41% |
2.29%
1.1 pts worse
|
Numerator 3 · Denominator 88 · Adjusted rate 3.89% |
| Healthcare-associated infections requiring hospitalization | 5.86% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 95 · Observed rate 2.11% · Lower 95% interval 2.8% |
| Staff COVID-19 vaccination coverage | 10.2% |
8.2%
2 pts better
|
Numerator 5 · Denominator 49 |
| Staff flu vaccination coverage | 88.89% |
42%
46.9 pts better
|
Numerator 40 · Denominator 45 |
| Discharge function score | 77.78% |
56.45%
21.3 pts better
|
Numerator 56 · Denominator 72 |
| Transfer of health information to provider | 75% |
95.95%
21 pts worse
|
Numerator 27 · Denominator 36 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 43 · Denominator 43 |
| Resident COVID-19 vaccinations up to date | 72.09% |
25.2%
46.9 pts better
|
Numerator 31 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.8% |
1.6%
6.2 pts worse
|
3.3%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.0% · Q3 11.5% · Q4 12.5% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
4.1%
2 pts worse
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 0.0% · Q3 5.0% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 1.2% |
13.7%
12.5 pts better
|
19.6%
18.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.4% |
14.2%
5.2 pts worse
|
16.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.6% |
11.0%
0.6 pts worse
|
16.3%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.0% |
10.7%
0.3 pts worse
|
14.9%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 9.5% · Q3 15.0% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.0%
0.4 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.9% |
1.2%
3.7 pts worse
|
1.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 12.0% · Q3 3.8% · Q4 0.0% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.9% |
10.9%
3 pts worse
|
19.8%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 16.4% · Q3 8.5% · Q4 17.1% · 4Q avg 13.9% |
| Percentage of long-stay residents with pressure ulcers | 9.8% |
4.7%
5.1 pts worse
|
5.1%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 8.0% · Q3 10.0% · Q4 15.7% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
94.0%
0.6 pts better
|
81.7%
12.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.9% · Q2 93.8% · Q3 95.8% · Q4 95.5% · 4Q avg 94.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.4% |
11.2%
6.2 pts worse
|
12.0%
5.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.4% · Observed 15.9% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 53.0% |
93.2%
40.2 pts worse
|
79.7%
26.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 53.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.0% |
23.2%
9.2 pts better
|
23.9%
9.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.0% · Observed 11.0% · Expected 18.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-14 · Fire 2024-06-14
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-12-09 · Fire 2022-12-09
3 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-29
F · Potential for more than minimal harm
2025-09-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-09-23
F · Potential for more than minimal harm
2025-09-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-09-19
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-09-30
C · Minimal harm
2025-09-19
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2025-09-26
C · Minimal harm
2025-09-19
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-10-03
C · Minimal harm
2025-09-19
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-10-03
C · Minimal harm
2025-09-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-01
F · Potential for more than minimal harm
2024-06-14
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-06-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-06-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-06-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-06-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-14
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-14
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-19
F · Potential for more than minimal harm
2022-12-09
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-01-17
F · Potential for more than minimal harm
2022-12-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-17
F · Potential for more than minimal harm
2022-12-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-17
E · Potential for more than minimal harm
2022-12-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-17
D · Potential for more than minimal harm
2022-12-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-01-17
D · Potential for more than minimal harm
2022-12-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-01-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-19
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-10-06
E · Potential for more than minimal harm
2025-09-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-06
E · Potential for more than minimal harm
2025-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-06
E · Potential for more than minimal harm
2025-09-19
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-19
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-19
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-03-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-25
G · Actual harm
2024-10-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-06-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-06-14
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-06-14
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-06-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-05
F · Potential for more than minimal harm
2022-12-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-27
D · Potential for more than minimal harm
2022-12-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-27
D · Potential for more than minimal harm
2022-12-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-27
Penalties and ownership
What sits behind the stars
$0
2024-10-25
Payment Denial
Payment Denial · denial start 2024-11-21 · 14 days
14 day denial
Ownership
Bank Of America, N.a.
5% Or Greater Security Interest · Organization
Bank Of America, N.a.
5% Or Greater Mortgage Interest · Organization
Castillo, Alika
W-2 Managing Employee · Individual
Cross, Lois
Corporate Director · Individual
Heard, David
Corporate Director · Individual
Kerr, Robert
Corporate Director · Individual
Lindsay, Dennis
Corporate Director · Individual
Pacific Retirement Services Inc
Operational/Managerial Control · Organization
Peralta, Gretchen
Corporate Director · Individual
Schrader, Wayne
Corporate Director · Individual
Sholty, Eric
Corporate Officer · Individual
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