University Park Care Center

Inspectors wroteBased on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for one of three abuse allegations. Specifically, the facility failed to thoroughly investigate an allegation of physical abuse involving Resident #1 on 8/2/25 in order to prevent a second incident from occurring on 9/13/25.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide the necessary treatment and services to treat and prevent pressure injuries for one (#42) of two residents out of 50 sample residents reviewed for pressure ulcers. Resident #42, who was dependent on staff for all care and mobility and was known to be at risk for skin breakdown, developed a stage 3 pressure injury on 5/20/24 at the facility. The resident's care plan for skin breakdown failed to include interventions for repositioning the resident frequently to avoid potential pressure injuries. Observations during the survey revealed staff were not repositioning Resident #42 frequently in order to keep the resident from developing further pressure injuries. [...]

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 on two of four units. Specifically, the facility failed to ensure glucometers were cleaned in a sanitary manner.

Inspectors wroteBased on interviews and record review, the facility failed to honor resident choices for two (#25 and #84) of two out of 50 sample residents. Specifically, the facility failed to ensure an effective system was established to honor and allow residents to make choices regarding their daily care.

Inspectors wroteBased on observations and staff interviews the facility failed to provide services for three (#24, #47, #157) of three residents out of 50 sample residents according to professional standards of practice. Specifically, the facility failed to: -Ensure safe medication administration practices were followed by administering medications immediately after preparation and not storing unadministered medications; and, -Ensure medications were not left at the bedside.

Inspectors wroteBased on record review and staff interviews, the facility failed to implement an effective antibiotic stewardship program that included an effective system of identification of newly prescribed antibiotics, tracking prophylactic antibiotic use and tracking infections that were prescribed antibiotics for four (#103, #84, #73, #60) of four residents out of 50 sample residents. Specifically, the facility failed to: -Track and monitor the use of short-term antibiotics which were prescribed for Resident #103 and Resident #84; and, -Track and monitor the use of long-term/prophylactic antibiotics which were prescribed for Resident #73 and Resident #60.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#26 and #25) of two residents with limited mobility reviewed for range of motion (ROM) out of 50 sample residents received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, the facility failed to: -Apply splints to ensure Resident #26 did not have a worsening contracture; and, -Ensure Resident #25 was placed on a restorative nursing program program, which was recommended by physical therapy.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication error rate was not five percent (%) or greater. Specifically, the medication administration observation error rate was 5%, or two errors out of 40 opportunities for error.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#24) of five residents out of 50 total sample residents was free from a significant medication error. Specifically, the facility failed to ensure the insulin pen was primed prior to insulin administration for Resident #24.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in accordance with professional standards on two of four units. Specifically, the facility failed to: -Ensure medications were stored in their original containers; and, -Ensure medications were stored in a sanitary manner, separately from food items.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents retained the rights to their personal belongings for one (#1) of three residents out of four sample residents reviewed for personal belongings. Specifically, the facility failed to ensure Resident #1's right to have personal property when the resident's tape recorder was removed from her bedside and locked in a medication cart without the resident's permission.

Inspectors wroteBased on record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences for two (#1 and #4) of three residents reviewed for pain management out of four sample residents. The facility failed to ensure Resident #1 was administered pain medication as ordered. The resident admitted to the facility from the hospital on 8/30/23 with acute compression fractures of the spine and increased back pain. Resident #1 was prescribed Tramadol (pain medication to treat moderate to severe pain) on admission to the facility as needed for pain related to acute spinal fractures and pain. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide an environment as free of accident hazards as possible and ensure residents received adequate supervision and assistance devices to prevent accidents for one (#1) of three residents reviewed for accident hazards out of three sample residents. Resident #1 had a diagnosis of dementia with wandering and resided in a secure unit. Resident #1 sustained nine falls from 9/17/23 to 11/27/23. The facility failed to ensure appropriate interventions and adequate supervision were implemented to prevent major injuries, including a fracture of the left and right hips, which were sustained in two separate falls. Due to the facility's failures to implement effective interventions and adequate supervision, Resident #1 sustained a fracture of the left hip from a fall on 10/7/23. [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to report an allegation of an injury of unknown source to the state survey agency for 1 (Resident #64) of 2 residents reviewed for abuse.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to have evidence that an injury of unknown source was investigated for 1 (Resident #64) of 2 residents reviewed for abuse. On 01/24/2023, staff observed Resident #64 to have a bruise on the left eye and the resident was unable to explain how the resident received the injury.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure: -Backflow prevention devices were installed on the hand held shower appliances in two hall of four hall showers, increasing the risk of contaminating the facility's main water supply.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure an effective program of pest management. Specifically, the facility failed to ensure the main kitchen, dining rooms, resident rooms and hallways were free from flies.

Inspectors wroteBased on observations and staff interview the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 13 of 98 resident rooms and on seven of seven hallways. Specifically, the facility failed to ensure: -Walls, ceilings and the entrance door were repaired, painted and properly maintained.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that infection control precautions designed to provide a safe and sanitary environment were followed by housekeeping staff. Specifically the facility failed to ensure housekeeping staff: -Adequately maintained hand hygiene in between cleaning multiple surfaces; -Changed gloves and sanitize hands in between cleaning multiple surfaces; and -Removed gloves and performed hand hygiene when leaving or entering a resident's room.

Inspectors wroteBased on record review and interviews, the facility failed to report an alleged violation of abuse to the State survey and certification agency in accordance with State law, for one (#72) of two residents reviewed for abuse out of 44 sample residents. Specifically, the facility failed to report allegations of physical abuse to the state agency in a timely manner. Cross-reference F610, failure to thoroughly investigate allegations of abuse in a timely manner.

Inspectors wroteBased on record review and staff interviews, the facility failed to thoroughly investigate an allegation of physical abuse involving one (#72) of two residents'reviewed for abuse of 44 sample residents. Specifically, the facility failed to thoroughly investigate an allegation of abuse in a timely manner.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide an ongoing activity program for three (#127, #123, and #72) of five residents reviewed out of 44 sample residents. Specifically, the facility failed to care plan and provide an individualized, person-centered, on-going activity program to meet the needs of Residents #127, #123, and #72.

Inspectors wroteBased on staff interviews and record review, the facility failed to provide pain management services for one (#134) of two out of 44 sample residents. Specifically, the facility failed to provide pain relief interventions including non-pharmacological and/or pharmacological methods that were available at the time of admission, to prevent Resident #134 from experiencing a pain level of 9 out of 10. The resident lost confidence in the facility's ability to provide pain relief services two hours after admission, which resulted in the resident and family making the decision to send the resident back to the hospital for pain relief services against facility staff advice.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to identify a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors for one (#127) of five residents reviewed of 44 sample residents. Specifically, the facility failed to care plan, identify, monitor, track, and address escalating behavioral issues since admission. Cross-reference to F679 Activities Meet Interest/Needs of Each Resident because the facility failed to care plan and provide an individualized, person-centered, on-going activity program to meet the needs of Residents #127, #123, and #72.