University Health and Rehabilitation Center

Inspectors wroteBased on observations, records reviewed and interviews it was determined that the facility did not adequately maintain a safe environment to prevent potential hazards that could have resulted in accidents or injuries in two of five soiled utility rooms. Staff failed to secure two soiled utility room doors on the facility's second floor because paper towels had been placed in the locks, which prevented proper locking. At the time of the survey 140 residents resided in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to store food under sanitary conditions as evidenced by the walk-in refrigerator contained flower bouquets on the shelves among the fruits and vegetables. This has the potential to affect 128 out of 133 residents who eat orally residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to secure confidential information for the residents on the fourth floor as evidenced by an observation of an unattended paperwork with residents' pictures, names and rooms left visible on top of the fourth floor's south medication cart. There were 24 residents residing on the fourth floor.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to update a respiratory care plan for one (Resident #79) out of one sampled resident as evidenced by a respiratory care plan with interventions for a Bilevel Positive Airway Pressure (BiPAP) machine, despite physician orders for the discontinuation of the BiPAP machine since 10/15/24. There were three residents with BiPAP machines in the facility at the time of survey.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to properly secure medications for residents residing on the fourth floor, as evidenced by a plastic bag with medications observed on top of the unattended fourth floor's south medication cart. There were 24 residents residing on the fourth floor at the time of survey.

Inspectors wroteBased on observations, interviews and record review, the facility failed to demonstrate effective action plans were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F812- Food Procurement, Store/Prepare/Serve - Sanitary and F867- Quality Assurance and Performance Improvement (QAPI)/ Quality Assessment and Assurance (QAA). These repeated deficient practices have the potential to affect all residents residing in the facility.

Inspectors wroteBased on records reviewed and interviews the facility failed to immediately inform the resident's representative and physician about an accident that resulted in an injury which required medical attention for one resident (Resident #1) out of four sampled residents, as evidenced by during assisted transfer Resident#1 hit her head on the wheelchair and the incident went unreported after bruising was identified and reported the family member to staff. There were 143 residents residing in the facility at the time of the survey.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one resident (Resident #1) out of four sampled residents received adequate supervision to prevent accidents as evidenced by during transfer, Resident #1 sustained injuries that were not reported immediately by staff and were discovered by a family member.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote dignity and respect for two residents (#41 and #93) out of 28 sampled residents. As evidenced by a Certified Nursing Assistant (CNA) was observed standing while feeding Resident #41 and Resident #93 not having any food while his roommate was being fed and eating food. There were 143 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide reasonable accommodations for Resident #343 as evidenced by Resident #343 call light was out of reach and had difficulty using other devices. There were 143 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation and interview the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, homelike environment and comfortable interior for 1 out of 3 residential floors (Resident rooms on 300 floor North Unit). The Findings Included: During the initial observations on 01/08/2024 beginning at 08:41AM of residents and residents' rooms revealed: room [ROOM NUMBER]B was noted with water stains on the wall and roof by the window (B Bed), (Photo Available). Rooms 307A, 308, 311B, 314B-Garbage on the floors-Straw wrapping, empty condiment packets, tissues, alcohol pad packets, and paper of different kinds (photo available). [...]

Inspectors wroteBased on Interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one resident (Resident # 139) out of one resident whose MDS assessments reviewed at the time of survey. This deficiency has the potential to affect 143 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure oxygen therapy was being received as prescribed for two Residents (#69 #46,) out of 28 sampled residents. As evidenced by several observations of Resident #46 revealed the oxygen was running at the incorrect rate. Resident #69's tracheostomy (trach) collar that provided oxygenation to the resident was dislodged from the trach opening and hanging to the right side of the resident's neck. There were 14 residents that required respiratory services out of the 148 residents residing in the facility at the time of the survey. The Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store food under sanitary condition by ensuring the ice cream freezer was properly defrosted and did not contain a buildup of ice. This has the potential to affect 139 out of 143 residents who eat orally residing in the facility at the time of the survey.

Inspectors wroteBased on record review and interview, the facility's quality assurance and assessment committee failed to identify quality concerns to implement effective plans of action related to resident rights, safe, clean, comfortable and homelike environment and food procurement, store, prepare and serve-sanitary resulting in repeated deficient practice. The facility was cited for Resident rights in 2022; Safe, clean, comfortable and homelike environment in 2022 and Food procurement, store, prepare and serve-Sanitary in 2022. These repeated deficiencies practice has the potential to affect any of the 143 residents residing in the facility.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety that include; maintenance of refrigeration units, holding of foods at regulatory temperatures, proper thawing of foods, and preparation of foods within clean areas.

Inspectors wroteBased on record review,observation and interview, it was determined that the the facility failed to treat residents with respect and dignity as evidenced by; 5 out of 18 residents sampled residents (Resident #2, Resident #12, Resident #54, Resident #76, and Resident #158) who drank thickened liquids from condiment cups, 119 resident were not provide with proper drinking cup/glass to pour milk into of which 2 out of 19 were sampled residents who were required to drink milk from the carton, 2 (Resident's #57 and Resident #69) 2 sampled residents were fed by standing staff, and 1 (Resident #48) of 1 sampled resident who was referred to as a feeder.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary , orderly, and comfortable interior for 3 of 3 resident floors (second, third, and fourth floors).

Inspectors wroteBased on record review, observations and interviews, the facility failed to comply with the state minimum staffing requirements for 48 consecutive hours and failed to comply with the stated minimum weekly average of 3.6 hours of care by direct care staff per resident per day. There were 140 residents residing in the facility at the time of the survey.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure that 1 of 3 (third floor unit) medication storage room was kept free of expired medications.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to prepare and serve food in a form (mechanical soft) to meet the individual needs of 53 facility residents that included 2 sampled residents (Resident #74 and Resident #103)

Inspectors wroteBased on record review, observation and interview it was determined that the facility failed to prepare and serve Carbohydrate Controlled therapeutic diet for 50 facility resident's that included 3 sampled residents (Resident #22, Resident #74, and Resident #88).

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide grooming of the fingernails for 2 of 3 sampled residents (Residents #12, Resident # 22) and failed to provide toenails care for 1 of 1 sampled resident (Resident #74).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure proper care of wounds for 1 of 1 resident reviewed for wound care, Resident #341.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 3 of 3 sampled residents (Resident #12, Resident # 47 and Resident # #54) for range of motion.

Inspectors wroteBased on record review, observations and interviews, the facility failed to perform hand hygiene between gloves changes during urinary catheter care for 1 of 1 resident sampled for catheter care (Resident #11).