University Health and Rehabilitation Center

Inspectors wroteBased on observations, staff interviews and manufacturer recommendations, the facility failed to date opened multi-dose vials of insulin medication in 2 of 4 medication administration carts (carts number 1 and 2) and failed to remove expired multi-dose insulin pens from the medication cart drawer for 3 of 4 medication administration carts reviewed (carts number 1, 2 and 3). Findings Included: A review of the manufacturer's recommendations, dated December 1st, 2021, indicated to discard Lantus insulin multi-dose vial 28 days after opening. A review of the manufacturer's recommendations, dated July 7th, 2023, indicated to discard Humalog insulin multi-dose vial 28 days after opening. On 4/13/26 at 10:35 AM, an observation of the medication administration cart #3 with Nurse #9 revealed one Humalog insulin pen, opened on 3/1/26 and one Lantus insulin pen, opened on 3/12/26. On 4/13/26 at 10: [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to label and date leftover frozen food that had been removed from its original packaging and failed to properly seal leftover frozen food stored in 1 of 1 reach in freezer. The facility also failed to clean food debris from under the steam table, black buildup substance around wall edges around kitchen wall perimeter and within floor tile grout lines. In addition, the facility failed to repair open holes under sinks, broken wall tile, damaged door molding, accumulated debris from an air duct vent, and a leaking water pipe under the sink located at the back of the kitchen. The deficient practice had the potential to affect food served to the residents and the cleaning and sanitation practices pose a potential risk for pests and contamination.

Inspectors wroteBased on observations, record review, and staff and Pest Control Technician interviews, the facility failed to maintain an effective pest control program as evidenced by the presence of roaches for 1 of 3 observations in the kitchen.

Inspectors wroteBased on record reviews, and resident, family member, and staff interviews, the facility failed to honor a resident's choice related to shower time for 1 of 5 residents reviewed for choices (Resident #53).

Inspectors wroteBased on record review, observations, resident and staff interviews, the facility failed to provide maintenance services necessary to ensure resident bathrooms were in good repair and maintained in a safe, homelike manner. Damaged sheetrock, damaged floor tile, shower tile with visible blackish-brown substance present, and a broken ceramic toilet tank lid were observed for 1 of 4 sampled residents (Resident #15) on 1 of 4 halls (Hall #1).

Inspectors wroteBased on observations, record review, and interviews with staff and the Nurse Practitioner (NP), the facility failed to provide an ongoing activity program that met the individual interests and needs to enhance the quality of life for 1 of 1 resident reviewed for activities (Resident #13).

Inspectors wroteBased on record review, observations, and interviews with the Nurse Practitioner, resident and staff, the facility failed to schedule a follow-up appointment with dermatology for 1 of 3 residents reviewed for non-pressure related skin conditions (Resident #35).

Inspectors wroteBased on record review, Nurse Practitioner and staff interviews, the facility failed to assess and obtain treatment orders for a resident admitted from the hospital with a pressure ulcer for 1 of 8 residents reviewed for pressure ulcers (Resident #125).

Inspectors wroteBased on observations and staff interviews, the facility failed to: 1) Label medications (meds) with the minimum information required, including the name of the resident, on 1 of 2 medication (med) carts observed (Med Cart #1); 2) Discard expired medications on 2 of 2 medication carts observed (Med Cart #1 and Med Cart #4) and in 1 of 1 Medication Storeroom (Nurse Station #2 Medication Storeroom); and 3) Store medications in accordance with the manufacturer's storage instructions on 1 of 2 med carts (Med Cart #1).

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to place a resident's call light within reach to allow for the resident to request staff assistance if needed for 1 of 1 resident reviewed for accommodation of needs (Resident #78).

Inspectors wroteBased on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of Preadmission Screening and Resident Review (PASRR) Level II status (Resident #23), use of a hypoglycemic medication (a medication that helps to lower blood sugar levels in people diagnosed with diabetes) (Resident #23), use of an antianxiety medication (Resident #52) and hypoglycemic medication was inaccurately coded as insulin (Resident #4) for 3 of 21 residents whose MDS assessments were reviewed.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to post cautionary signage outside the resident's room to indicate supplemental oxygen was in use for 1 of 3 residents reviewed for respiratory care (Resident #85).

Inspectors wroteBased on record reviews, and staff, Nurse Practitioner (NP), responsible party, and Resident interviews, the facility failed to notify the physician and responsible party of changes in condition for of 1 of 1 resident (Resident #7). Resident #7 had intact cognition and a history of stroke and on 10/21/24 at approximately 9:00 PM he reported to a nurse aide (NA) he had pain and numbness in his left arm and leg. The NA aide reported this to the nurse. On the next shift at approximately 6:00 AM Resident #7 informed another NA he could not feel his left side. The NA reported this to the nurse. On 10/22/24 between 7:00 and 7:15 AM Unit Manager (UM) #1 was called to the room by an NA and assessed Resident #7 and found his speech was slurred, his left arm and leg did not have any feeling, and they did not have any muscle tone. [...]

Inspectors wrote2. Resident #7 was admitted to the facility on [DATE], with diagnoses of history of right hemiparesis/hemiplegia (partial or complete paralysis of one side) with right side weakness related to a stroke, Type 1 diabetes mellitus. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #7 was cognitively intact and had functional impairment of the lower extremities bilaterally with use of a wheelchair, set up assistance for eating and oral hygiene/care, dependent care for toileting, showers, and lower extremity dressing including shoes, and maximum assistance for repositioning, sitting from lying, and transfers. The care plan dated 9/7/24 indicated that Resident #7 had a communication problem related to hearing loss (Right), hemiplegia/hemiparesis related to a stroke, needed assistance with transfers, mobility. [...]

Inspectors wroteBased on record reviews and staff interviews, the facility failed to complete a performance review every 12 months for 5 of 5 nurse aides (NAs) reviewed (NA # 4, #5, NA 7, NA #9 and NA #10).

Inspectors wroteBased on record review, resident, staff, Physician, and Nurse Practitioner (NP) interviews the facility failed to ensure a resident (Resident #1) had a Pulmonary consultation appointment ordered once on 4/13/24 and again on 5/10/24. Resident #1 was diagnosed with obstructive sleep apnea and the appointment was required so Resident #1 could obtain a continuous positive airway pressure (CPAP) machine (used to treat sleep apnea by keeping the airways open while sleeping) that was ordered on 4/13/24. The facility also failed to ensure Resident #1 attended a Neurology consultation appointment ordered on 8/24/24 which was made due to Resident #1 complaining of constant migraines/headaches. This occurred for 1 of 3 residents reviewed for medically related social services.

Inspectors wroteBased on observations, record review, and staff and service technician interviews the facility failed to cover facial hair and wear gloves during food preparation; keep food service equipment clean and free from debris and maintain a clean kitchen environment; label and date open food items in 1 of 1 walk in coolers; maintain and monitor the kitchen's dish machine that was utilized to clean the dishware and eating utensils to ensure the machine's wash cycle and rinse cycle temperature reached a minimum temperature of 120 degrees Fahrenheit (F); and insulated dome lids and bases were dry before they were stacked for use.

Inspectors wroteBased on observations and staff interviews the facility failed to maintain a clean and sanitary environment as evidenced by the presence of a growth buildup in and on 1 of 2 ice machines observed and various colored growths on the floor for 1 of 2 observations that were conducted for clean and sanitary environment.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain the privacy of a resident's record by leaving a medication cart laptop unattended, with resident health information exposed in an area accessible and visible to the public, for 1 of 4 medication carts (Zone 1 medication cart).

Inspectors wroteBased on observations and staff interviews, the facility failed to secure resident medications left in an unattended medication cart for 1 of 4 medication carts (Zone 1 medication cart).

Inspectors wroteBased on record review, resident, staff, and Physician interviews, the facility failed to maintain an accurate medical record regarding the use of a Continuous Positive Airway Pressure (CPAP) machine for 1 of 1 resident (Resident #1) reviewed for professional standards.

Inspectors wroteBased on record review, staff interview, pharmacist and physician interview the facility failed to notify the pharmacy of missing insulin for 1 of 3 resident reviewed for pharmacy services (Resident #2).

Inspectors wroteBased on record review, staff interview and physician interview the facility failed to follow physician order for 1 of 3 residents reviewed for pharmaceutical services (Resident #2).

Inspectors wroteBased on record review and staff and physician interviews the facility failed to safely transfer a resident when utilizing a sit to stand lift for 1 of 3 residents reviewed for accidents (Resident #1). This unsafe transfer resulted in Resident #1 sustaining a mildly displaced left medial malleolus (boney presence on the inner side of the ankle) fracture and pain of 5 on a scale of 1 to 10 (10 being the worst pain).

Inspectors wroteBased on record review and interviews with staff and the physician, the facility's Quality Assessment and Assurance (QAA) committee failed to self-identify the need for the development and implementation of an effective plan to achieve and sustain compliance in the area of supervision to prevent accidents (F689). This was evidenced by a repeat issue with staff failing to transfer residents safely related to an incident that occurred on 11/30/23 and an incident that occurred on 2/14/24. This repeat failure shows a pattern of the facility's inability to sustain an effective QAA program.

Inspectors wroteBased on record review, resident, staff, Physician, Psychiatric Nurse Practitioner, and Administrator interviews the facility failed to protect a resident's right to be free from employee to resident physical abuse, when an employee (receptionist) threw a plexiglass (acrylic) mask holder hitting Resident #2 on his forehead. The resident had a fall, and a laceration on his forehead. The resident was angry and upset when he was hit by the object thrown by the staff member. Resident #2 was sent to the emergency room and had undergone a procedure for 5 sutures on his forehead. This was for 1 of 2 residents reviewed for abuse (Resident #2).

Inspectors wroteBased on staff interviews and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions put into place by the Committee after each of the following surveys with citations that were recited on the current complaint survey of 3/6/24: 1) A complaint investigation survey of 1/14/22. This was evident for one recited deficiency in the area of Freedom from Abuse and Neglect (F600). 2) The annual recertification / complaint investigation survey of 8/18/22. This was for one recited deficiency in the area of Request / Refuse / Discontinue Treatment; Formulate Advance Directives (F578). 3) A complaint investigation survey of 3/16/23. This was evident for recited deficiency in the area of Reporting Alleged Violations (F609). [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure advanced directive information was up to date in the resident's electronic medical record for 1 of 1 resident (Resident #8) reviewed for advanced directives. Findings Included: Resident #8 was initially admitted to the facility on [DATE], with her latest admission date of 11/21/23. The resident was admitted to hospice on 1/16/24. Resident #8 passed away on 2/2/24 at the facility. Review of the physician orders for Resident #8 showed an order dated 8/23/22 that read full code. Review of hospice medical record showed a DNR form for Resident #8 dated 1/16/24. Review of hospice progress note for Resident #8 completed by a contract hospice nurse dated 1/16/24 showed DNR (Do Not Resuscitate). The note further read, a copy will need to be signed and taken to facility. [...]

Inspectors wrote2. Resident #5 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with psychotic disturbances and reduced mobility. Resident #5 was discharged from the facility on 11/6/23. Review of a nursing progress note dated 10/18/23 at 3:01 P.M. written by Nurse #3 read in part Pt (Patient) tearful and bruising noted to arm. Pt states someone with a hoodie hit her in the arms and knees about a week ago. She does not know who but thinks it was about a week ago. No markings to knees. No c/o (complaints of) pain. This was relayed to the nurse manager (Nurse # 4) who states she thinks the bruising is cellulitis. Will continue to monitor. [...]

Inspectors wroteBased on observations, interviews with residents, staff, and the Medical Doctor (MD), and record reviews, the facility failed to safely transfer a resident using a total mechanical lift for 1 of 1 resident (Resident #1) reviewed for accidents. The resident was lowered to the floor by two staff members without injury as the mechanical lift tipped to one side.

Inspectors wroteBased on the [NAME] Payroll Based Journal (PBJ) for fiscal year Quarter 2 2023 (January 1 - March 31) report, record review and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day for 8 of 31 days reviewed. (3/4/23, 3/5/23, 3/10/23, 3/11/23, 3/12/23, 3/17/23, 3/18/23, and 3/19/23).

Inspectors wroteBased on observations, interviews, and record review the facility failed label foods in the walk-in refrigerator, walk-in freezer and in two (2) of two (2) nourishment refrigerators. The facility failed to ensure the food in walk-in freezer was free of ice and failed to maintain the back splash behind the stove free of grease. These practices had the potential to affect food being served to residents.

Inspectors wroteBased on observations, resident and staff interviews and record review, the facility's quality assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification and complaint surveys dated 8/18/22 to achieve and sustain compliance. This was for recited deficiencies on a recertification survey on 9/14/23. The deficiencies were in the areas of Request/Refuse/Discontinue Treatment; Formulate Advance Directives and Registered Nurse (RN) 8 hours (hrs.)/7 days a week, full time Director of Nursing (DON). The continued failure during the federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program.

Inspectors wroteBased on record review, and staff and resident interviews, the facility failed to invite the resident or resident responsible party to participate in the care planning process for 1 of 18 residents whose care plans were reviewed (Resident #27).

Inspectors wroteBased on records review, and staff interviews, the facility failed to have Advance Directives (code status) in the residents' records for 1 of 1 resident reviewed for Advance Directives (Resident #3).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to remove an expired multi-dose vial of insulin and failed to date opened medications in 1 of 5 medication administration cart (Cart #2). Findings Included: On 9/11/23 at 10:10 AM, an observation of the medication administration cart #2 with Nurse #5 revealed one, half-empty multi-dose vial of Glargine insulin, opened on 8/8/23. A review of the manufacturer's literature indicated to discard the insulin multi-dose vial 28 days after opening (5/9/23); one opened and undated multi-dose vial of Levemir insulin. A review of the manufacturer's literature indicated to discard the insulin multi-dose vial 42 days after opening: two opened and undated inhalation containers of Symbicort 160/4.5 mcg (microgram) and one opened and undated inhalation container of Breztri Aerosphere. [...]

Inspectors wroteBased on the daily staffing sheets, actual working assignment sheets and staff interview, the facility failed to post accurate daily nurse staffing information for 8 out of 62 days for March 2023 and August 2023 reviewed for staffing.