University Park Nursing and Rehabilitation Center

Inspectors wroteBased on observations, clinical record review, staff interview, and policy review the facility failed to disinfect a mechanical lift after use between 2 of 2 residents (#37, #55) and failed to use appropriate Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) and enteric isolation precautions for 2 of 2 residents (#13, #75). The facility reported a census of 74 residents.

Inspectors wroteBased on clinical record review, staff and resident interview, and facility policy review, the facility failed to provide showers for dependent residents in 1 of 18 resident's reviewed for activities of daily living (ADLs) (Resident #58). The facility reported a census of 74.

Inspectors wroteBased on observation, clinical record review, staff interview, and policy review, the facility failed to correctly position a resident in a mechanical lift during transfer for 1 of 3 residents (#14), failed to lock the wheelchair during resident transfers for 2 of 3 residents (#44, #55), and failed to attach foot pedals on the wheelchair while transporting a resident for 1 of 1 resident (#69). The facility reported a census of 74 residents.

Inspectors wroteBased on observation, electronic health record (EHR) review, staff interviews, and policy review, the facility failed to assure a medication error rate of less than 5%. A total of 27 ordered medications were reviewed with two errors, an error rate of 7.4%. The facility reported a census of 74.

Inspectors wroteBased on observation, policy, Electronic Health Record (EHR) review and staff interview the facility failed to follow the menu and prepare food to meet the residents nutritional needs for 1 of 13 residents (Resident #6) reviewed. The facility reported a census of 72 residents.

Inspectors wroteBased on observation, Electronic Heath Record (EHR) review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with a surgical wound, a pressure wound and a resident with a wound vacuum, that were on Enhanced Barrier Precautions (EBP) for 3 of 3 reviewed (Resident #3, #4, and #7). The facility reported a census of 72 residents.

Inspectors wroteBased on personnel document review, staff interviews, and facility policy review the facility failed to employ a clinically qualified nutrition professional by not having a certified dietary manager. The facility reported a census of 17 residents.

Inspectors wroteBased on documentation review, staff interviews, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility failed to document temperatures of food in the kitchen prior to distribution. The facility reported a census of 76 residents.

Inspectors wroteBased on observations, staff interviews, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility placed cooking utensils on countertops, and delivered drinks uncovered. The facility reported a census of 76 residents.

Inspectors wroteBased on observation, record review, resident interviews, staff interviews and policy review, the facility failed to assure residents were treated with respect and dignity for 2 of 3 residents reviewed (Resident #84 and #54). The facility reported a census of 76 residents.

Inspectors wroteBased on observation, staff interviews and policy review, the facility failed to maintain resident living areas in good repair and provide a homelike environment. The facility reported a census of 76 residents.

Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to ensure residents were free from misappropriation of resident property for 1 of 1 resident's reviewed (Resident #35). The facility reported a census of 76 residents.

Inspectors wroteBased on observation, family and staff interview, and policy review, the facility failed to ensure call light was within reach for 1 of 19 residents reviewed (Resident #68). The facility reported a census of 76.

Inspectors wroteBased on observation, resident and staff interviews, record review and policy review, the facility failed to have sufficient nursing staffing to respond to resident's needs in a timely manner after a call light was activated. The facility reported a census of 76 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to notify the Long Term Care Ombudsman of discharge/transfer of residents as required for 5 of 5 residents reviewed who were discharged or transferred from the facility (Residents #5, #14, #23 #42, and #59). The facility reported a census of 79 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews and facility policy review, the facility failed to provide a sanitary environment to help prevent the spread of communicable disease and infections. The facility failed to perform hand hygiene, don gloves, change gloves and use a barrier under a graduate during catheter drainage for 3 of 3 residents reviewed (Resident #51, #11 and #61). The facility reported a census of 79 residents. 1. The Minimum Data Set (MDS) assessment for Resident #51 dated 1/3/2024, included diagnoses of non-Alzheimer's dementia and obstructive uropathy (condition that blocks the flow of urine). The MDS documented the resident had an indwelling catheter (tube to drain urine from the bladder). The MDS documented a Brief Interview for Mental Status (BIMS) score of 8 completed, indicating moderate cognitive impairment for decision-making. [...]

Inspectors wroteBased on observations, clinical record review, staff interview and facility policy review the facility failed to ensure each resident received necessary respiratory care and services in accordance with professional standards of practice by providing oxygen (O2) without a physician's order and not changing oxygen tubing for 1 of 1 resident (Resident #73) reviewed. The facility reported a census of 79 residents.

Inspectors wroteBased on observations, resident and staff interview, and policy review, the facility failed to ensure a safe, clean, and homelike environment for 2 of 2 nursing units. The facility reported a census of 80 residents.

Inspectors wroteBased on clinical record review, staff interviews, and information from the Davis's Drug Guide, the facility failed to consistently report weight loss to the physician for 1 of 1 residents (Resident #4) reviewed who was prescribed a dosage of a weight based medication. The facility reported a census of 80 residents.

Inspectors wroteBased on clinical record review, observations, resident and staff interviews, and staff competency checklist, the facility failed to ensure a mechanical (Hoyer) lift in a safe and functional condition to safely transfer a resident for 1 of 4 residents observed during a transfer (Resident #10). The facility staff also failed to ensure a proper sized sling used for transfer of a resident in a mechanical lift for 1 of 4 residents observed for transfers (Resident #13). The facility reported a census of 80 residents.

Inspectors wroteBased on clinical record review, observations, staff interview, and facility peri-care competency checklist, the facility failed to provide incontinence care to minimize the risk and occurrence of urinary tract infections for two of four residents observed for incontinence care (Resident #10 and Resident #6). The facility reported a census of 80 residents.

Inspectors wroteBased on observations, staff interviews, resident council meeting, and facility policy review, the facility failed to ensure staff responded and answered residents' call lights within 15 minutes and met residents needs in a timely manner for one of two nursing units observed. The facility reported a census of 80 residents.