University Heights Care Center

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an effective pest control program so the environment was free of pests. Specifically, the facility failed to prevent and take adequate measures to eliminate cockroaches within the facility kitchen, the resident dining room, resident rooms, resident shower rooms and in the facility hallways.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#6) of three residents reviewed were free from abuse out of 18 sample residents. Specifically, the facility failed to protect Resident #6 from physical abuse by certified nurse aide (CNA) #7.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a thorough investigation of alleged misappropriation of funds for two (#1 and #4) of two residents out of 18 sample residents. Specifically, the facility failed to maintain thorough documentation that an alleged violation was thoroughly investigated for the misappropriation of Resident #1 and Resident #4's funds/property.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to: -Ensure enhanced barrier precautions (EBP) were followed;-Ensure hand hygiene was performed during medication administration;-Ensure hand hygiene was performed during cleaning of resident rooms; and,-Ensure urine collectors were bagged, dated and labeled when not in use.

Inspectors wroteBased on record review and interviews, the facility failed to ensure consent was obtained for the use of psychotropic medications for one (#16) out of five residents reviewed for unnecessary medications out of 43 sample residents. Specifically, the facility failed to obtain consent prior to the administration of an antipsychotic antidepressant medication for Resident #16.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#59 and #63) of three residents reviewed for activities of daily living (ADL) received the necessary care and services to maintain their ADL abilities out of 43 sample residents. Specifically, the facility failed to:-Ensure Resident #59 consistently received assistance with personal hygiene, such as showering, shaving and trimming his nails; and,-Provide language communication tools for Resident #63 in order for her to effectively communicate her needs.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide the necessary services for one (#14) of four residents reviewed for services to maintain highest practicable quality of life out of 43 sample residents. Specifically, the facility failed to ensure Resident #14 consistently received assistance with dining.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide two (#63 and #31) of three residents reviewed for activities with an ongoing program of activities designed to meet needs and interests and promote physical, medical and psychosocial well-being out of 43 sample residents. Specifically, the facility failed to ensure Resident #63 and #31 received a personalized activity program.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries from occurring or worsening for one (#38) of three residents reviewed for pressure injuries out of 43 sample residents. Specifically, the facility failed to ensure staff consistently provided care planned interventions to Resident #38, who was admitted to the facility with a stage 4 pressure injury to his sacrum (a triangular bone at the base of the spine that is formed by the fusing of the sacral vertebrae).

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents with indwelling catheters received the appropriate care and services according to professional standards for one (#12) of two residents reviewed for catheter care out of 43 sample residents. Specifically, the facility failed to ensure Resident #12's catheter tubing and catheter bag were positioned below the resident's bladder.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#82) of three residents out of 43 sample residents. Specifically, the facility failed to:-Ensure an assessment was completed to identify potential trauma behaviors for Resident #82, who had a diagnosis of post-traumatic stress disorder (PTSD); and,-Develop a care plan for Resident #82's PTSD that included possible escalating triggers (stimuli that cause a person to experience intense emotional distress or for the person to react in ways that were reminiscent of past traumatic experiences) and appropriate interventions.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#42) of two residents reviewed for medications errors out of 42 sample residents. Specifically, the facility failed to ensure that Resident #42 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper storage of medications in two of four medication storage carts and one of two medication storage rooms. Specifically, the facility failed to: -Ensure medications were labeled with the date they were opened; and,-Ensure expired medications were removed and discarded from medication carts.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#14) of two residents reviewed for hospice services out of 43 sample residents. Specifically, the facility failed to ensure the hospice agency notes regarding Resident #14's care were easily accessible to the facility staff in an attempt to effectively coordinate care with the hospice agency.

Inspectors wroteBased on record review and interviews, the facility failed to ensure three (#13, #1 and #6) of five residents out of 13 sample residents were kept free from abuse. Specifically, the facility failed to: -Ensure Resident #13 and Resident #1 were kept free from physical abuse by Resident #2; and, -Ensure Resident #6 was kept free from physical abuse by Resident #7.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#4) of three residents reviewed for accidents out of 12 sample residents. Specifically, the facility failed to: -Ensure Resident #4 was provided with the supervision necessary to prevent elopement; and, -Ensure Resident #4's elopement on 3/2/25 was investigated thoroughly.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#2) of five residents out of 13 sample residents who were diagnosed with dementia, received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. Specifically, the facility staff failed to implement person-centered interventions to prevent Resident #2 from displaying physically aggressive behaviors toward other residents related to her diagnosis of dementia.

Inspectors wroteBased on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in two of two nourishment rooms. Specifically, the facility failed to: -Ensure frozen nutritional supplements and thickened liquids were dated appropriately; -Ensure timely cleaning of the ice machine; -Ensure food was labeled and dated in the nourishment rooms; -Ensure food was properly cooled; and, -Ensure food was reheated appropriately.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure garbage and refuse was properly disposed of and the dumpster lid was closed to prevent harborage to pests and insects for two of three dumpster areas. Specifically, the facility failed to ensure garbage and potentially hazardous medical waste was disposed of in the proper receptacles or dumpster.

Inspectors wroteBased on record review and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included all resources, education, staff competencies and facility based risk assessments.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to infection control. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to infection control.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases, including COVID-19, for 10 (#72, #26, #79, #24, #38, #4, #81, #52, #11, #17 and #56) of 10 residents reviewed for COVID-19 immunizations out of 52 sample residents. Specifically, the facility failed to ensure tracking, offering and administration of the COVID-19 vaccination.

Inspectors wroteBased on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal and influenza vaccinations for 11 (#72, #26, #79, #24, #38, #4, #81, #52, #11, #17 and #56) of 11 residents out of 52 sample residents. Specifically, the facility failed to: -Administer the pneumococcal vaccination after Resident #72, #79, #4 consented to the vaccination; -Obtain a physician's order to administer the annual influenza vaccination for Resident #72, #26, #79, #24, #38, #4 and #11; -Determine if additional doses of the pneumococcal vaccination were needed and offer the additional doses of the pneumococcal vaccination as needed to Resident #26, #24, #35, #52, #17, and #56; -Document declination forms, document risk versus benefit education and re-offer the pneumococcal vaccination annually for Resident #81 and #11; [...]

Inspectors wroteBased on observations and interviews, the facility failed to provide a comfortable and homelike environment for the residents on two of two units in the facility. Specifically, the facility failed to ensure residents were provided with clean washcloths and hand towels in their rooms on the South and North units.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure menus were followed to meet the residents nutritional needs. Specifically, the facility failed to: -Follow correct portion sizes to ensure adequate nutrition was provided to the residents; and, -Follow recipe modifications for minced and moist diets.

Inspectors wroteBased on observations, record review and interviews, the facility failed to consistently serve food that was palatable, attractive at the appropriate temperatures and met the nutritional needs of the residents. Specifically, the facility failed to ensure the residents' food was palatable in taste, texture and appearance.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide food and beverages that accommodated resident preferences for five (#66, #79, #59, #14 and #83) of five residents reviewed food and beverage preferences out of 52 sample residents. Specifically, the facility failed to offer food choices to residents who preferred to eat in their room for Residents #66, #79, #59, #14 and #83. I. Facility policy The Resident Food Preferences policy, revised July 2017, was received from the corporate nurse consultant (CC) #1 on 1/23/24. It read in pertinent part: Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#79) of one out of 52 sample residents. Specifically, the facility failed to ensure Resident #79 was assessed for safe self-administration of medications.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were provided prompt efforts by the facility to resolve any grievances for one (#16) of one resident reviewed for grievances out of 52 sample residents. Specifically, the facility failed to ensure grievances regarding missing clothing items was followed up timely with a satisfactory resolution for Resident #16.

Inspectors wroteBased on interviews and record review, the facility failed to take steps to protect one (#6) of three residents out of 52 sample residents. Specifically, the facility failed to ensure Resident #6 was free from physical abuse from Resident #11.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents received pre-admission mental health screenings for one (#24) of one resident reviewed for mental health screenings out of 52 sample residents. Specifically, the facility failed to perform a level two pre-admission screening and resident review (PASRR) for Resident #24.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement an effective discharge plan for one (#79) of one resident reviewed for discharge planning out of 52 sample residents. Specifically, the facility failed to assist Resident #79 with his discharge planning goals.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#79) of two residents reviewed for vision out of 52 sample residents. Specifically, the facility failed to offer vision services to Resident #79.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#38 and #79) of three residents reviewed for pain out of 52 sample residents had an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences. Specifically, the facility failed to: -Ensure Resident #79 was referred to a pain clinic in a timely manner after the physician requested a pain clinic referral; -Thoroughly document Resident #38's pain level after administration of as needed (PRN) pain medication and the non-pharmacological interventions used prior to administration; -Ensure prescribed PRN pain medication was administered prior to wound care according to the physician orders; -Thoroughly and accurately complete pain assessments for Resident #38; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the necessary care and treatment to prevent the development of pressure injuries for one (#74) of two residents reviewed of 39 sample residents. Resident #74 was admitted to the facility on [DATE] with diagnoses of pressure ulcer of sacral region stage four, spinal stenosis (narrowing of spine), dementia, and chronic pain syndrome. The resident was admitted with hospice care and was followed by the wound physician. The resident was admitted with one stage 4 pressure ulcer to her sacrum. On 3/29/22 the resident developed a stage 2 pressure ulcer to her right lateral knee. On 4/19/22 the right lateral knee wound had developed to a stage 4 and a stage 2 pressure ulcer to the right scapula had developed. On 5/17/22 the right scapula wound had developed to a stage 4. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#74) of three out of 39 sample residents received the care and services necessary to meet their nutritional needs and to maintain their highest level of physical well being. Resident #74 was admitted to the facility on [DATE]. Diagnoses included pressure ulcer of sacral region stage four, gastro-esophageal reflux, dementia, and chronic pain syndrome. The resident was admitted with one stage 4 pressure ulcer to her sacrum and later developed three additional pressure ulcers. Dietary interventions included Mighty Shakes and Ensure Plus (nutritional supplements) with no additional interventions trialed as the resident's wounds continued to deteriorate (cross-reference F686 for pressure injuries). In August 2022, a 34.2 pound weight loss was noted with a reweight requested to verify weight loss. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were properly stored and labeled in two medication carts and one storage room out of four medication carts and two storage rooms. Specifically facility failed to: -Ensure loose medications in carts were properly disposed of; -Ensure the temperature of the refrigerator was kept within a safe range; -Ensure medications were not poured from one bottle to another; -Ensure medication carts were locked when unattended; and, -Ensure proper disposal of medications.

Inspectors wroteBased on resident interviews, staff interviews, record review, and the tasting of the test tray, the facility failed to consistently serve food that was palatable and at the proper temperature. Specifically, the facility failed to ensure resident food was palatable in taste, texture, appearance, and temperature.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases and infections. Specifically, the facility failed to: -Ensure resident rooms were cleaned appropriately; -Ensure proper infection control procedures were followed during wound care; and, -Enusure proper infection control procedures during medication administration. I. Failed to appropriately clean resident rooms A. Professional reference Centers for Disease Control and Preventions: [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure two (#440 and #339) of two residents reviewed received services in the facility with reasonable accommodation of resident's needs of 39 sample residents. Specifically, the facility failed to ensure: -Resident #440's room was set up so the resident was able to access items such as her call light, nightstand and bedside table, have access to her television remote and orient the resident on how to work her television, which was her preferred activity (cross-reference F679); and, -Resident #339 had access to her walker which provided independence.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to develop and implement a baseline care plan for one (#440) of one resident reviewed for baseline care plans out of 39 sample residents. Specifically, the facility failed to fully develop, review with the resident, and implement within 48 hours of admission, a person-centered baseline care plan for Resident #440 to include resident care focus areas, goals of care and interventions.

Inspectors wroteBased on interviews and record review, the facility failed to ensure two (#8 and #64) of four residents out of 39 sample residents for assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to provide Resident #8 and #64 with bathing according to their plan of care.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a program to support residents in their choice activities, designed to meet the interests and support the physical, mental, and psychosocial well being of each resident, encouraging independence for one (#440) of one out of 39 sample residents. Specifically, the facility failed to ensure Resident #440 was offered and assisted with independent leisure activities in her room. Cross-referenced to F558 failure to accommodate resident needs.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (#72) of four out of 39 sampled residents. Specifically, the facility failed to ensure a treatment order was in place for an open area for Resident #72.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#44 and #77) of six out of 39 sample residents with limited range of motion (ROM) received appropriate treatment and services. Specifically the facility failed to: -Ensure Resident #44 and #77 were provided braces, for contracture management, according to their plan of care; and, -Ensure parameters were clearly identified to indicate the length of time and how often the braces should be donned and doffed by the Resident #44 and #77.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide an environment free of accidents and hazards for two (#44 and #50) of five out of 39 sample residents. Specifically, the facility failed to ensure Resident #8 and Resident #44 did not have medications and supplements in their rooms.

Inspectors wroteBased on record review and interviews, the facility failed to ensure three residents (#29, #36 and #64) of five out of 39 sampled residents were free of unnecessary medication as possible. Specifically, the facility failed to: -Ensure informed consent was obtained prior to administration of psychotropic medication for Resident #29 and #64; and, -Ensure a gradual dose reduction (GDR) recommendation was followed for Resident #36.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure drinks and fluids were provided consistent with the preferences and choices for one (#440) of one resident reviewed for hydration out of 39 sample residents. Specifically, the facility failed to ensure Resident #440 was provided water and drinks of choice daily and the drinks were within reach when provided in her room.