University Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1), when Licensed Nurses (LNs) did not follow their policy and procedure related to medication administration. This failure had the potential for medication error.

Inspectors wroteBased on observation , interview and record review, the facility failed to ensure clean and used utensils were separated during a preparation of pureed meals. This failure had the potential to affect the health and safety of all residents. An observation on 5/5/25 at 10:30 A.M., was conducted with the [NAME] (CK) and the registered dietician (RD). The CK was observed preparing a pureed meal for 9 residents in the facility. The CK placed 20 pieces of tortillas and 3 cups of turkey meat in a chicken broth and placed them in a blender. The CK used a large mixing spoon to mix the tortillas and the turkey meat in the blender. The CK stated she wanted to make sure that the mixture was smooth and was free of lumps after blending the ingredients together. Then the CK placed the large mixing spoon in a tray of clean mixing spoons and colored scoops together. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete Physician Orders for Life Sustaining Treatment (POLST - a medical form to communicate a resident's end of life wishes) for three of 18 residents (4,128, 129) reviewed for complete and accurate medical records. This failure did not provide an accurate representation of the care provided and had the potential to cause confusion amongst care providers.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure infection control practices were implemented when: 1. Clean linens were mixed with packages that were transported from outside facility 2. Trash cans were inside the clean linen closets 3. Dusty and debris on the floor of the clean linen closets 4. A licensed nurse (LN 21) did not wear an isolation gown while administering medications to a resident (1) with a gastrostomy tube (GT-feeding tube inserted through the belly to bring nutrition and medications directly to the stomach). These failures had the potential to spread infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services to meet professional standards for two of 18 sampled residents when: 1. Resident 129's PICC line (peripherally inserted central catheter- a thin tube placed in the vein of the upper arm and threaded towards the heart to deliver medications directly to the blood stream) 2. a gastrostomy tube (GT-tube inserted through the belly to bring nutrition and medications directly to the stomach) placement was not checked before medication administration for one resident (1). This failure had the potential for complications related to intravenous (IV - method of delivering medications directly into the bloodstream through a vein) therapy and causing complications related to GT health.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently provide pressure ulcer preventative measures to one resident (178) when, Resident 178 was not turned every two hours. This failure had the potential for Resident 178 to develop pressure ulcers or skin breakdowns.

Inspectors wroteBased on observation , interview and record review, the facility failed to ensure a tube feeding formula was labeled for one resident (178) reviewed for Parenteral Nutrition. This failure had the potential to affect Resident 178 health conditions and decline.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 sq ft. ( square feet) per resident in nine of 39 resident rooms. This failure had the potential to affect resident quality of care and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement a care plan (detailed plan with information about a patient's treatment, goal, and interventions) related to medication administration for one of three sampled residents (Resident 1). This failure had the potential to not meet the goals of treatment and needs of Resident 1.

Inspectors wroteBased on interview and record review, the Licensed Nurses (LNs) failed to administer Levothyroxine (a medicine used to treat an underactive thyroid gland [hypothyroidism]) within the time frame as ordered by the physician for Resident 1. This failure had the potential to negatively affect Resident 1's absorption of the medication and had the potential for ineffective medication.

Inspectors wroteBased on interview and record review the facility failed to ensure that a Certified Nursing Assistant (CNA) and a Licensed Nurse (LN) provided by an agency (a company that supplies staff) had the necessary competency to document care during their shift. As a result, CNA 1 did not document any care provided for Resident 1, sampled for death, and LN 1 documented medications were given late. Additionally, no change of condition documentation and physician notification were done regarding abnormal laboratory results, and no follow-up social services notes were documented for Resident 1's roommate who was in the room when he died. The facility was not able to provide requested evidence of the events prior to Resident 1's death in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent an accumulation of old food and beverage items at the bedside of one resident, Resident 2, sampled for infection prevention. The facility also failed to provide regular showers or bed baths and clean clothing to Resident 2 who had open sores on his arms and face. As a result, Resident 2 was at risk for foodborne illness and infection of his open wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide documented evidences that the maintenance department was proactive in documenting weekly maintence checks for room and facility temperatures during extreme temperature changes. As a result, the facility was unable to show documented evidence the facility and room temperatures were safe and comfortable over the past year.

Inspectors wroteBased on an interview and record review, the facility failed to ensure that pressure injuries (also known as pressure ulcers or bed sores, which are areas of skin and tissue damage caused by prolonged or intense pressure) were documented in the medical record every week per the facility's policy for one of three sampled residents (Resident 1). As a result, Resident 1's progression or deterioration of the pressure injury could not be accurately assessed.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure dignity was provided to the residents when a staff member did not knock or announce herself before entering two residents' rooms (Resident 1 and unsampled residents). This failure had the potential to make residents feel disrespected and may have resulted in diminished quality of life and lower self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to follow the plan of care for monitoring a recently placed suprapubic catheter (a surgically inserted flexible tube that drains urine from the bladder into an external drainage bag), for one of three residents (Resident 1), reviewed for comprehensive care plans and following the physician ' s order. As a result, there was the potential for Resident 1 ' s suprapubic catheter to develop an infection or become dislodged when unmonitored routinely by staff.

Inspectors wroteBased on interview and record review, the facility failed to provide pain relief in a reasonable amount of time, following a recently placed suprapubic catheter (a surgically inserted flexible tube that drains urine from the bladder into an external drainage bag), for one of three residents (Resident 1), reviewed for pain management. As a result, Resident 1 had no pain relief for 6.5 hours, delaying his comfort and healing process.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan related to skin integrity for one of one resident with a rash (Resident 2). Failure to develop a care plan related to skin integrity had the potential for residents to not receive appropriate care and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate respiratory (relating to breathing) care and services were given to four residents when: 1. The physician's order for oxygen therapy was not followed for three residents. (Resident 3, Resident 4, and Resident 6) 2. There was no Oxygen in use sign on the doors for two residents (Resident 2 and Resident 4) and, 3. A resident ' s BIPAP (machine used as breathing support and administered through a face mask or nasal mask) nasal mask was exposed and not stored correctly. In addition, staff did not know when and how to clean the BIPAP ' s tubing and nasal mask. (Resident 2) This failure had the potential for residents to have further respiratory problems, and infection from an unclean respiratory equipment. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide behavioral health care and services for two residents when: (Resident 1 and Resident 3) 1. Residents 1 and 3 both had a history of substance abuse were not referred to an addiction treatment program or for drug counseling services, 2. Residents 1 and 3 did not have a specific resident centered care plans (an approach to care that places a patient's needs and desires first) regarding substance abuse interventions. As a result, Resident 1 was transferred to the hospital and was diagnosed with Fentanyl (a highly addictive pain medication) overdose, and an unknown white powdery substance was found in Resident 3's room.

Inspectors wrote4. Resident 14 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing foods or liquids) and dementia (a disease that affects the brain's ability to think, remember and reason) per the facility's admission Record. A review of Resident 14's nutritional risk assessment on admission, dated 10/10/22, indicated Resident 14 had chewing and swallowing problems and was at high risk for aspiration (when food or liquid enters the airway and lungs). A review of Resident 14's speech therapy evaluation (STE), dated 10/10/22 indicated the resident wore dentures. A review of Resident 14's diet orders, dated 2/17/23, indicated Resident 14 had was on a regular diet, mechanical soft (easy to chew) with ground meat texture and thickened liquids. On 2/16/23 at 11:37 A.M., an observation and interview with Resident 14 was conducted in her room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmacy services to meet the needs of the residents by failing to: 1. Remove a discontinued medication from the medication cart for a discharged resident in a timely manner; 2. Label with the time and date of activation (contact between previously separated diluent and medication) of the Mini Bag Plus - piperacillin/tazobactam (antibiotic for injection into vein) vial system before storage in the medication refrigerator; 3. Clarify a physician order to provide pain medication only for moderate pain for one of five residents reviewed (Resident 8); and 4. Correctly administer a pain medication based on the perceived level of pain for one of five residents reviewed (Resident 33). 5. Correctly ensure that medication was stored in the correct location for one of 19 sampled residents (70). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an adequate handwashing sink with soap in the kitchen. This failure had the potential to increase the risk of food-borne illness.

Inspectors wroteBased on interview and record review, the facility's QAPI/QAA (quality assessment performance improvement/quality assessment and assurance) committee failed to identify, develop, and implement action plans related to the residents discharging from the facility against medical advice (AMA). Cross reference F622. This failure had the potential to affect the health and safety of the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four residents (18) reviewed for discharge, was permitted to remain in the facility when: 1. The facility initiated Resident 18's discharge as AMA (against medical advice). 2. Licensed nurse (LN) 2 did not verify that Resident 18's order for discharge came from the physician. 3. There was no documentation in Resident 18's clinical record that the AMA discharge was resident-initiated. 4. Facility policies for discharge and leaving AMA were not implemented. In addition, when the facility discharged Resident 18 home on 1/30/23, the resident was unable to use the stairs to access his home, the resident had been sent home with medications/treatments he did not know how to administer to himself, and was not provided with home health services. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party of discharge for one Resident (11).

Inspectors wroteBased on observation,interview and record review, the facility failed to revise a care plan for falls for one Resident (13). This failure had the potential to increase the risk of falls for Resident 13.

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge summary for one Resident (11). This failure had the potential to cause a decrease in communication for post-discharge information for the resident and the care-giver.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities designed to meet the interests of one of one resident (41) reviewed for Activities. This failure had the potential to effect resident 41's physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident (13) was provided proper eyeglasses. This failure had the potential to affect Resident 13's vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 396), had her oxygen therapy monitored and documented accurately. This failure resulted in an over-administration of oxygen and had the potential to slow Resident 396's heart and breathing rate, and cause lung damage.

Inspectors wroteBased on interview and record review, the facility failed to ensure one medication to treat high blood pressure was not administered in excess of the dose ordered by the physician when one medication order was duplicated and administered twice each day for one of five residents reviewed (Resident 33). This had the potential to significantly lower the blood pressure to cause dizziness, confusion, fainting and a fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure use of psychotropic medications for sleep ordered as PRN (as needed) by the physician for residents did not exceed beyond 14 day without being re-ordered by the physician. This had the potential for unnecessary medications to be administered to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was an open date written on the insulin pen when it was removed from the medication refrigerator and stored in the medication cart at room temperature. This had the potential for the medication to be less effective, or for an expired medication to be administered to the resident.

Inspectors wroteBased on interview and record review, the facility's medical director failed to ensure policies and procedures were implemented related to residents leaving/discharging the facility against medical advice (cross reference F622). As a result, there was a potential for residents to be inappropriately discharged from the facility without the necessary care and services, which could potentially result in physical and psychosocial harm to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate documentation of medication for two of 18 residents (Resident 70 and 396). This failure had the potential to result in inadequate pain control and oxygen toxicity (damage to the lungs from too much oxygen).

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection prevention controls when oxygen tubing was not changed weekly, per the facilities expected practice, for two of 19 residents (20, 28) reviewed for infection control. As a result, there was a potential for germs to enter the respiratory tract of resident's causing an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 sq. ft. (square feet) per resident in nine of 39 resident rooms. This failure had the potential to affect resident quality of care and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with respect and dignity for three of 21 sampled residents and three unsampled residents when: 1. A staff member did not wait for a resident's response before entering and did not introduce themselves upon entering the resident's room (49), 2. Staff did not talk to or sit down with residents (10, 45, 331, 2) who relied on staff for assistance with their meals; and, 3. A staff member did not provide care in a respectful manner for one resident (22). 1. Resident 49 was admitted to the facility on [DATE], per the facility's Resident Face Sheet. On 8/22/19, a review of Resident 49's MDS (health status screening and assessment tool), Section C, dated 7/15/19, indicated Resident 49's BIMS Summary Score (test for cognitive function) was 13 out of 15 (score of 13-15 indicated cognition was intact). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food was prepared in accordance with professional standards of food service safety when the food processor was not properly cleaned between preparing puree vegetables and chicken. This failure had the potential for cross-contamination (when germs are unintentionally transferred from one item to another) and the potential for foodborne illness.

Inspectors wroteBased on observation and record review the facility failed to provide at least 80 sq. ft. (square feet) per resident in nine of 39 resident rooms. This failure had the potential to affect resident quality of care and quality of life.