University City Rehabilitation and Healthcare Ctr

Inspectors wroteBased on review of facility documentation, review of clinical records, and interview with staff it was determined that the facility failed to implement interventions to reduce the risk of accident/hazards for one of two residents reviewed (Resident R1). Findings Include: Review of Resident 1's clinical record on July 28, 2026, revealed the resident was admitted to the facility on [DATE], and has a Brief Interview for Mental Status (BIMS - cognitive assessment used to evaluate memory and orientation) score of 13 (cognitively intact). [...]

Inspectors wroteBased on record review, staff interview, and physician documentation, the facility failed to ensure that residents were free from significant medication errors for 1 of 2 sampled residents (Resident R2) reviewed for medication administration.

Inspectors wroteBased on observation, record review, review of facility policy, interview with staff and residents, it was determined that the facility did not ensure that medications were stored and labeled according to professional standards for one of five residents reviewed. (Resident R1)

Inspectors wroteBased on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility did not ensure that the medication error rate was less than five percent for two of five residents observed during medication administration (Resident 53 and Resident 110). Findings Include: The facility's medication error rate was 20% based on observation of 25 medication administration opportunities with five errors observed. Review of facility policy, Administering Medications revised April 2019, revealed, Medications are administered in accordance with prescriber orders, including any required time frame. Further review of facility policy indicates Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). [...]

Inspectors wroteBased on review of facility documentation, review of clinical records, and staff interview it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers to the hospital for one of two residents reviewed for hospitalizations (Resident R10). Findings Include: Review of Resident R10's clinical record revealed a nursing note dated November 10, 2025, which indicated that the resident had a change in condition and was ordered by the physician to be transferred to a local hospital for evaluation. Review of Resident R10's clinical record revealed no documented evidence that the Office of the State Long-Term Care Ombudsman was notified of the facility-initiated emergency transfer. Interview on January 9, 2026, at 11:54 a.m. [...]

Inspectors wroteBased on clinical record review, observation, and staff interviews, it was determined the facility did not provide services in accordance with accepted professional standards of quality related to daily weights for one of 26 clinical records reviewed (R19). Findings Include: Record review of Resident 19's medical record revealed a physician order for daily weights for cardiac monitoring with active dates 12/15/2025 through 1/12/2026. Cardiac documentation stated: [R19] was seen on cardiac rounds today. She was coughing, crackles to lower base with rhonchi. Jugular vein slightly distended. [ R19's] diuretic dose was changed. CXR ordered. BNP ordered. Changes discussed with resident. UM to put resident on report so that staff can monitor patient and maintain her daily weights. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff interview it was determined that the facility failed to maintain personal care needs for dependent residents for two of 26 residents reviewed (Resident R68 and R10). Findings Include: Findings Include:Review of facility policy Activities of Daily Living (ADL), Supporting revealed appropriate care and services are provided for residents who are unable to carry out ADLs independently, to include hygiene (bathing, dressing, grooming, and oral care). Review of Resident R68's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated December 10, 2025, revealed the resident had impairment in functional limitation in range of motion in the upper and lower extremity and required set-up assistance with personal hygiene. [...]

Inspectors wroteBased on review of facility documentation, review of clinical records, observations, and staff interviews it was determined that the facility failed to provide treatment/services for a resident with limited mobility/range of motion to increase range of motion and/or to prevent further decrease for one of 4 residents reviewed (Resident R10). Review of Resident R10's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated November 17, 2025, revealed the resident was assessed with severe cognitive impairment and had diagnoses of arthritis (joint inflammation), aphasia (communication deficits), and hemiplegia (one sided paralysis) or hemiparesis (one sided muscle weakness). [...]

Inspectors wroteBased on interviews and the review of clinical records, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of three Dialysis-Residents reviewed (Residents R32).

Inspectors wroteBased on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that medications were stored in accordance with currently accepted professional principles for one of three medication carts reviewed (second floor front cart/cart 1). Findings Include:Review of facility policy, Medication Labeling and Storage, revealed that Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. Further review of facility policy indicates that, 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Additionally, policy states, 4. [...]

Inspectors wroteBased on clinical record review, observation, and interview, the facility failed to ensure timely follow-up and provision of recommended dental services for a resident with an identified dental need for one of 26 residents reviewed (Resident R95).

Inspectors wroteBased on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to medication administration (Residents R110, R117, R49 and R53) and Enhanced Barrier Precautions for two of 10 residents reviewed (R32, R49).

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure that two of two passengers elevators were in operating condition. (#1 and #2 elevators)

Inspectors wroteBased on observations, and staff interviews, it was determined that the facility failed to ensure that a 1 out of 3 residents reviewed was assess for self administration of medications. (Resident R3).

Inspectors wroteBased on review of clinical records, staff interviews and review of facility policy, it was determined that the facility failed to ensure that grievences were investigated and prompt efforts were made to resolve grievances for 1 out of 2 residents reviewed (Resident R1).

Inspectors wroteBased on review of clinical records, facility policy and interview with staff, it was determined that the facility failed to conduct a complete and through investigation for an allegation of potential abuse/neglect for 1 out of 2 residents reviewed (Resident R1).

Inspectors wroteBased on staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to notify the physician when residents did not receive their hemodialysis treatment from the onsite dialysis center for 2 out of 2 residents reviewed (Resident R1 and Resident R2).

Inspectors wroteBased on observations, staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure that medications were properly labeled and stored according to professional standards for 1 out of 3 residents reviewed (Resident R3).

Inspectors wroteBased on the review of clinical records, interviews with staff, it was determined that the facility failed to administer medication as ordered by the physician for one of 8 residents reviewed. (Resident R1). Findings Include: Interview with Resident R1 conducted on May 8, 2025, at 10:00 a.m. revealed that the nurse does not apply the moisturizer cream, she is supposed to do it all the time. Review of Resident R1's clinical record revealed resident was admitted to the facility on [DATE]. Review of physician orders for Resident R1 revealed an order dated February 26, 2025, which indicated Apply moisturize cream within 3 mins of shower to lock in moisture (CervaVe, Eucerin, Cetaphil, Aveeno) Repeat application as needed to establish dry areas. Review of Resident R1's clinical record revealed that the resident receives showers on Tuesdays and Fridays during the week. [...]

Inspectors wroteBased on observations and resident and staff interviews, it was determined that the facility failed to maintain the facility in a clean, comfortable, and homelike condition for four of 15 residents reviewed (R12, R13, R14 and R15).

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that residents were evaluated for self-administration of medications for two of 30 residents reviewed (Residents R114 and R12).

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that a resident's right to request or refuse medical treatments were accurately reflected in the resident's record for one of 30 residents reviewed (Resident R86).

Inspectors wroteBased on review of facility policy, review of clinical record, review of facility documentation, and interviews with staff, it was determined the facility failed to to ensure that residents were free from resident to resident abuse for two of 30 residents reviewed. (Resident R77)

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital for one of 3 residents reviewed for hospitalization. (Resident R15)

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to develop baseline care plans related to bathing and enhanced barrier precautions for two of 30 residents reviewed (Residents R114 and R277).

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide assistance with bathing and eating for two of 30 residents reviewed (Residents R114 and R78).

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to administer medications in a timely manner for three of 30 residents reviewed (Residents R107, R277 and R278).

Inspectors wroteBased on observation, interviews with resident and staff, review of clinical records and facility policy, it was determined that the facility failed to maintain a peripheral inserted central catheter (PICC) consistent with professional standards of practice and in accordance with physician orders and the comprehensive person-centered care plan, for one of 24 residents reviewed (Resident R110).

Inspectors wroteBased on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for three of three medication carts reviewed (first floor front, middle and back medication carts).

Inspectors wroteBased on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that insulin pens were labeled in accordance with currently accepted professional principles for two of three medication carts reviewed (first floor back and middle medication carts).

Inspectors wroteBased on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide foods in accordance with residents' preferences for two of 30 residents reviewed (Residents R278 and R40).

Inspectors wroteBased on observations, interviews with staff, review of clinical records and facility policy, it was determined the facility failed to utilize enhanced barrier precautions during medication administration for one of three reviewed residents with feeding tubes (Resident R105).

Inspectors wroteBased on observations and interviews with residents and staff, it was determined that the facility failed to ensure that call devices were functional and accessible to residents for two of 30 residents reviewed (Residents R55 and R78).

Inspectors wroteBased on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food that was palatable and served at the proper temperature for two of 4 residents reviewed (Resident R1 and R2).

Inspectors wroteBased on reviews of resident clinical records, facility policies and procedures, and interviews with staff and residents, it was determined that the facility failed to follow physician orders for one of 4 residents reviewed. (Resident R2)

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for five of nine residents reviewed (Residents R2, R3, R4, R5 and R6).

Inspectors wroteBased on record review, and staff interviews, it was determined that the facility failed to maintain clinical records on each resident in accordance with accepted professional standards related to documentation of risk and benefits of the influenza vaccine, pneumococcal vaccine and COVID-19 vaccine for seven of eight resident records reviewed. (Residents R342, R347, R341, R81, R346, R103 and R64).

Inspectors wroteBased on review facility policy, review of clinical record review, observations and staff interviews, it was determined that the facility failed to maintain an effective infection control program during medication administration for residents (Residents R75, R23 and R15) for 3 out of 3 residents observed during medication administration.

Inspectors wroteBased on observation, clinical record review and staff interview, it was determined that the facility failed to ensure that a resident was evaluated for self administration of medications for one of 24 residents reviewed. (Resident R9)

Inspectors wroteBased on observations and resident interviews, it was determined that the facility failed to maintain the facility in a clean, comfortable, and homelike condition for three of 26 residents reviewed (Resident R11, Resident R2 and Resident R341).

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility failed to ensure that comprehensive resident assessments were completed in a timely manner for three of six discharged records reviewed (Residents R67, R110 and R111).

Inspectors wroteBased on clinical record review, staff interview and review of facility policy, it was determined that the facility failed to ensure that a pain medication patch was properly label for one of 24 residents reviewed. (Resident R80)

Inspectors wroteBased on observations, review of clinical record , review facility policy and staff interviews, it was determined that the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one of 26 residents reviewed (Resident R24).

Inspectors wroteBased on facility policy and observation and interviews, it was determined the facility failed to ensure appropriate enteral feeding practices relating to labeling for two of eight residents observed for tube feeding. (Residents R332 and R80).

Inspectors wroteBased on a review of clinical records, review of facility documentation, review of facility policy and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for two of 26 residents reviewed (Resident R63 and R101). Findings Include: Review of the undated Medication Regimen Review Policy revealed, the consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. The consultant pharmacist provides the director of nursing and medical director with a written, signed and dated copy of all medication regimen reports. [...]

Inspectors wroteBased on review of personnel records and staff interviews, it was determined that the facility failed to properly document the dates of tuberculin skin test results for newly hired staff members on four of five personnel records reviewed (Employeess E17, E18, E19 and E20).

Inspectors wroteBased on observation, staff and resident interview, it was determined that the facility failed to ensure that call bells were available and operable for resident use for three of 26 residents interviewed. (Residents R184, R8 and R22)

Inspectors wroteBased on clinical record review, facility policy and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of 2 residents with weight loss reviewed (Resident R4).

Inspectors wroteBased on review of facility policy, pharmacy documentation, review of clinical records, interview with staff and residents, it was determined that the facility failed to ensure that medications were administered in accordance with professional standards for one of seven residents reviewed. (Resident R7)

Inspectors wroteBased on observation, staff interviews, and review of facility policy, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards for one of two medication carts observed (second floor cart).

Inspectors wroteBased on staff interviews, review of facility documentation, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure that an allegation of possible sexual abuse was reported to the Nursing Home Administrator in a timely manner for one out of three residents reviewed (Resident R3).

Inspectors wroteBased on staff interviews, review of the facility policy and review of facility documentation, it was determined that the facility failed to ensure that an allegation of abuse submitted to the State Survey Agency contained complete and accurate information for one out of three residents reviewed (Resident R3).

Inspectors wroteBased on observations, interview with resident and staff, and review of facility policy, it was determined that the facility did not ensure that a resident was provided with a shower as ordered by the physician and according to the resident's individual needs for one of 57 residents reviewed (Resident R7)

Inspectors wroteBased on observations, interview with staff and resident and review of facility policy, it was determined that facility did not provide food that accommodates resident's preferences for one of one residents reviewed. (Resident R7)