University Post Acute

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure the Speech Therapist's ST - a speech language pathologist who assess and treat people who have speech, language, voice and swallowing disorders) recommendation was followed for 1 (one) of 9 (nine) residents (Resident 22), since June 27, 2025. This failure had the potential to place Resident 22's health at risk and to miss identifying any undetected disease. During a review of Resident 22's admission Record (contains demographic and medical information), it indicated, Resident 22 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing), moderate protein calorie malnutrition (poor intake leading to weight loss or weakness) and dementia (a group of diseases and illnesses that affect thinking, memory, reasoning, personality, mood and behavior). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a physician's order for RNA (Restorative Nursing Assistant, staff trained to help residents maintain or improve function) to perform AAROM ( active - assisted range of motion) was implemented for one (1) of nine (9) sampled residents (Resident 4) when there was no documented evidence that the AAROM was provided to Resident 4, since October 17, 2025. This failure placed Resident 4 at risk for functional decline due to the inability to verify that restorative nursing services were implemented as ordered. [...]

Inspectors wroteBased on observation, and interview, the facility failed to ensure resident bedrooms meet the required minimum 80 square feet (sq. Ft) per resident for 19 of 21 rooms measured in the facility (room [ROOM NUMBER]-8 and 11-21). This failure had the potential to affect the resident's health and safety and prevent the residents from maintaining their highest level of well-being by limiting the movements of these residents in their rooms. During an environmental tour with the Maintenance Supervisor (MS), on November 18, 2025, at 4:16 PM, nineteen of the 21 resident rooms were observed to be less than 80 sq. ft. per resident. The residents' rooms and their measurements of livable space were noted as follows:1. room [ROOM NUMBER], the total floor area measured 292.8 sq ft and four beds occupied the room, which yielded 73.2 sq ft for each resident.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to its safety and supervision of resident ' s policy when one of the three sampled residents (Resident 1) left the facility without the staff ' s knowledge. This failure resulted in Resident 1 eloping for a duration of approximately 6 hours and traveling a distance of about 17 miles away from the facility, posing a potential safety risk to the clinically compromised resident (Resident 1).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed ensure the accuracy of the Minimum Data Set (MDS) assessment for 2 (Resident 41 and Resident #45) of 13 sampled residents. Specifically, the facility failed to code Resident #41 received hospice care and Resident #45 received an antidepressant medication.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to ensure a preadmission screening and resident review (PASARR) evaluation was completed when a resident received a new mental diagnosis for 1 (Resident #18) of 3 sampled residents reviewed for PASARRs.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to ensure a preadmission screening and resident review (PASARR) evaluation was completed for 1 (Resident #6) of 3 sampled residents reviewed for PASARRs.

Inspectors wroteBased on interview and document review, the facility failed to ensure residents room' measured at least 80 square (sq) feet (ft) per resident in 19 (Rooms 1 - 8 and 11-21) 21 resident rooms in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sanitary kitchen, when there where dead insects and cobwebs under the shelves in the dry storage and behind the stove. This had the potential to contaminate the food and food contact surfaces in a highly susceptible population of 43 residents.

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - facility assessment tool), for three of three residents reviewed for resident assessment (Resident 5, 18, and 27) when: 1. One of Resident 5's active diagnoses was not coded. 2. Resident 18's Clopidogrel, an antiplatelet (medication that prevents blood cells from sticking together forming a clot) was coded as an anticoagulant (medication that prevents the formation of blood clots) in Resident 18's MDS, dated [DATE]. 3. Resident 27's Clopidogrel, an antiplatelet was coded as anticoagulant in Resident 27's MDS, dated [DATE]. These failures had the potential to result in unmet care needs for Resident 5, 18, and 27 which can negatively affect their health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) were re-evaluated after a Significant Change in Status Assessment (SCSA- a comprehensive Minimum Data Set [MDS- a facility assessment tool] assessment done for resident that must be completed when a resident meets the significant change guidelines for either improvement or decline), for three of three residents reviewed for PASRR (Residents 9, 18, and 33). These failures had the potential for Residents 9, 18, and 33 not to receive the care and services most appropriate for their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure an individualized comprehensive care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) was initiated, for one resident reviewed for mood/behavior (Resident 5) when a care plan was not initiated for Resident 5's diagnosis of depression and use of anti-depressant medication in accordance with the facility's policy and procedure. This failure had the potential to cause inadequate management of Resident 5's medical condition, affecting Resident 5's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plans were updated and revised in a timely manner when there was a change in anti-anxiety medication for one of five residents (Resident 8). This failure had the potential to result in inadequate treatment and management of resident's overall clinical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an opened emergency drug kit (eKIT) containing Schedule II (two) controlled substances (drugs stored and handled with additional restrictions to prevent abuse, addictions, and unauthorized use) in the Medication/Supply Room was replaced in a timely manner in accordance with the facility's policy. This failure had the potential to result in increased risk of drug diversion (illegal distribution) and/or medication availability issues for a universe of 43 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5%. Two medication errors for Resident 3 occurred out of a total 34 medication pass opportunities. The medication administration error rate was 5.88%. This failure had the potential to expose residents to preventable medication errors which could adversely affect their health and safety.

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe infection control program when outdated supplies were available for resident use in the Medication/Supply Room. This failure had the potential for a universe of 43 residents to be treated with ineffective or deteriorated (reduced quality) supplies which could negatively impact wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.) of livable space per resident for 19 of 21 resident rooms. This failure had the potential to affect the resident's health and safety and prevent the residents from maintaining their highest level of well-being by limiting the movements of these residents in their rooms.