Inspection Reports for University Nursing & Rehab Ctr
180 EPPS BRIDGE RD, ATHENS, GA, 30606
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 28, 2025, found deficiencies related to sprinkler system maintenance and smoke barrier construction. Earlier inspections showed a pattern of Life Safety Code issues including emergency preparedness, exit maintenance, and fire safety, as well as health-related deficiencies involving resident care such as nail care, environmental maintenance, and kitchen cleanliness. Complaint investigations were mostly unsubstantiated, though a substantiated complaint in May 2023 involved delayed reporting of a resident-to-resident abuse incident. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility has shown some correction of prior deficiencies over time, but Life Safety Code and maintenance issues have recurred in recent inspections.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
104% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
105 residents
Based on a May 2025 inspection.
Census over time
Inspection Report
Life Safety
Deficiencies: 2
Date: May 28, 2025
Visit Reason
A Life Safety Code Revisit survey was conducted to verify correction of previously cited Life Safety Code deficiencies.
Findings
The survey found that all previously cited Life Safety Code deficiencies had been corrected except for issues related to sprinkler system maintenance and smoke barrier construction. Specifically, the sprinkler system riser room was not protected from freezing and had non-working lighting, and smoke barriers throughout the facility had improper rated materials sealing penetrations.
Deficiencies (2)
Sprinkler system riser room not protected from freezing conditions and lighting not working.
Smoke fire barriers improperly maintained with penetrations sealed with improper rated materials throughout the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings during the facility tour. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 8, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for University Nursing & Rehab Center following a regulatory inspection.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Renewal
Census: 105
Deficiencies: 0
Date: May 8, 2025
Visit Reason
A health survey was conducted as a Recertification in conjunction with a Complaint Investigation survey that was concluded on April 3, 2025.
Complaint Details
The visit was related to a Complaint Investigation survey concluded on April 3, 2025.
Findings
All deficiencies cited as a result of the Recertification and Complaint Investigation survey were found to be corrected.
Inspection Report
Life Safety
Census: 99
Capacity: 119
Deficiencies: 8
Date: Apr 8, 2025
Visit Reason
The inspection was conducted as a Life Safety Code Survey to assess compliance with fire safety and emergency preparedness regulations at University Nursing and Rehab Center.
Findings
The facility was found not in substantial compliance with multiple Life Safety Code requirements, including emergency preparedness plan deficiencies, means of egress maintenance, exit signage, sprinkler system maintenance, smoke barrier integrity, gas and electric utilities safety, door maintenance, and portable space heater protections.
Deficiencies (8)
Emergency Preparedness Plan was not in substantial compliance, specifically documentation needing update with current transportation provider.
Failed to ensure that means of egress have been properly maintained, affecting 3 of 5 exit discharges within compartments.
Exit signage improperly maintained with incorrect chevron placement affecting the kitchen area.
Sprinkler system maintenance and testing deficiencies including loaded heads throughout the facility and other maintenance issues.
Smoke barriers not properly maintained with penetrations and improper rated materials used to seal penetrations throughout the facility.
Multi-taps throughout the facility were not properly secured from damage.
Rated doors, corridor doors, and exit doors throughout the facility would neither close, latch, seal properly, or were damaged.
Portable space heaters present without proper documentation in admissions office and reception desk.
Report Facts
Census: 99
Total Capacity: 119
Exit discharges affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during the inspection tour and interviews |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 3, 2025
Visit Reason
A State Licensure survey was conducted at University Nursing and Rehab Center from March 31, 2025, through April 3, 2025, by Healthcare Management Solutions, LLC on behalf of the Georgia Department of Community Health to assess compliance with state health regulations.
Findings
The survey identified multiple deficiencies including failure to provide adequate nail care for residents, unsafe environmental conditions in several resident rooms, and poor kitchen cleanliness that could potentially affect resident safety and health.
Deficiencies (3)
Failure to ensure nail care was provided for two of three residents reviewed for activities of daily living, resulting in excessively long fingernails and toenails.
Failure to provide necessary maintenance to five of 49 rooms creating unsafe, uncomfortable, and unhomelike environment for eight residents.
Failure to maintain cleanliness of the kitchen, including missing floor tiles, buildup of grime and dust on equipment and vents, and unsecured electrical outlets, creating potential for contaminated food to be served.
Report Facts
Residents reviewed for environment: 29
Rooms with maintenance issues: 5
Residents affected by maintenance issues: 8
Residents receiving oral diet: 102
Residents potentially affected by kitchen cleanliness: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 6 | Licensed Practical Nurse | Interviewed regarding resident nail care and facial hair responsibilities |
| Certified Nursing Assistant 12 | Certified Nursing Assistant | Interviewed regarding responsibilities for trimming residents' fingernails, toenails, and facial hair |
| Director of Nursing | Director of Nursing | Interviewed regarding responsibility for resident nail and facial hair care |
| Dietary Manager | Dietary Manager | Interviewed regarding kitchen cleanliness and maintenance issues |
| Corporate Maintenance Director | Corporate Maintenance Director | Interviewed regarding maintenance issues and cleaning responsibilities |
| Administrator | Administrator | Interviewed regarding maintenance director turnover and cleaning contracts |
Inspection Report
Routine
Census: 98
Deficiencies: 3
Date: Apr 3, 2025
Visit Reason
A standard survey was conducted from March 31, 2025 through April 3, 2025, including investigation of Complaint Intake Number GA00254432, which was found to be unsubstantiated.
Complaint Details
Complaint Intake Number GA00254432 was investigated in conjunction with the standard survey and was found to be unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to maintain a safe and homelike environment in resident rooms, inadequate nail care for residents, and failure to maintain kitchen cleanliness, potentially affecting resident safety and care.
Deficiencies (3)
Facility failed to provide necessary maintenance to five rooms creating an unsafe, uncomfortable, and unhomelike environment for eight residents.
Facility failed to ensure nail care was provided for two residents, resulting in unmet care needs.
Facility failed to maintain cleanliness of the kitchen, creating potential for contaminated food to be served to 97 of 102 residents.
Report Facts
Residents present: 98
Rooms with maintenance issues: 5
Residents affected by maintenance issues: 8
Residents reviewed for environment: 29
Residents with unmet nail care needs: 2
Residents receiving oral diet: 97
Total residents receiving oral diet: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 6 | LPN | Verified long toenails of resident R85 and discussed responsibility for nail care |
| Certified Nursing Assistant 12 | CNA | Discussed responsibility for trimming residents' nails and facial hair |
| Director of Nursing | DON | Discussed responsibility for nail care and facial hair grooming |
| Corporate Maintenance Director | Commented on maintenance issues and lack of stable Maintenance Director | |
| Administrator | Commented on turnover of Maintenance Directors and cleaning responsibilities | |
| Dietary Manager | DM | Provided information on kitchen cleaning and maintenance issues |
Inspection Report
Abbreviated Survey
Census: 103
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
An Abbreviated Partial/Extended Survey was conducted to investigate complaints GA00254158 and GA00253267.
Complaint Details
Complaints GA00254158 and GA00253267 were investigated and found to be unsubstantiated.
Findings
The complaints GA00254158 and GA00253267 were unsubstantiated, and no deficiencies were cited related to these complaints.
Inspection Report
Abbreviated Survey
Census: 106
Deficiencies: 0
Date: Dec 4, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints received against the facility.
Complaint Details
Complaints GA00249915, GA00243047, GA00243048, GA00248252, GA00250018, GA00251929, GA00252899, and GA00252992 were unsubstantiated. Complaint GA00248813 was substantiated. No deficiencies were cited for any complaints.
Findings
Most complaints were unsubstantiated except for one complaint which was substantiated. No deficiencies were cited related to any of the complaints.
Report Facts
Complaints investigated: 9
Facility census: 106
Inspection Report
Deficiencies: 0
Date: Jan 31, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for University Nursing & Rehab Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Census: 90
Deficiencies: 0
Date: Jan 31, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited during the 12/9/2023 Recertification Survey and Complaints Investigation Survey.
Findings
All deficiencies cited as a result of the 12/9/2023 Recertification Survey and Complaints Investigation Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 30, 2024
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies and to review the Emergency Preparedness Program compliance.
Findings
The Emergency Preparedness Program was found to be in substantial compliance with regulatory requirements, and all previously cited deficiencies were corrected.
Inspection Report
Annual Inspection
Census: 90
Deficiencies: 7
Date: Dec 9, 2023
Visit Reason
A State Licensure survey was conducted at University Nursing and Rehab Center from December 5, 2023 through December 9, 2023 to determine compliance with the State Long Term Care Requirements.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy and confidentiality, inadequate transfer and discharge procedures, failure to provide timely dental care and follow-up, improper infection control practices, failure to adhere to transmission-based precautions, and a medication error rate exceeding acceptable limits. Additionally, the facility failed to implement comprehensive person-centered care plans related to dental services for one resident.
Deficiencies (7)
Posting signage containing clinical information in a resident's room and allowing electronic medical record screens to be visible in hallways, violating resident privacy and confidentiality.
Failure to provide written notice of transfer or discharge and discharge summaries for several residents, and failure to notify the Ombudsman in writing.
Failure to provide timely assistance and follow-up for dental care for one resident, including lack of referral to an oral surgeon as recommended.
Failure to maintain proper infection control and prevention related to storage of resident personal care items and failure to serve food to residents in isolation using transmission-based precautions.
Failure of staff to properly wear masks covering nose during the inspection period.
Failure to ensure medication error rate was less than five percent; observed four medication errors out of 26 opportunities (15.38%).
Failure to implement comprehensive person-centered care plan related to dental services for one resident.
Report Facts
Medication errors: 4
Medication error rate: 15.38
Facility census: 90
Residents sampled: 52
Residents with infection control issues: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Certified Medication Aide (CMA) | Named in medication administration and confidentiality findings. |
| GG | Licensed Practical Nurse (LPN) | Named in medication administration and transfer notification findings. |
| HH | Licensed Practical Nurse (LPN) | Named in medication administration findings. |
| DON | Director of Nursing | Provided multiple interviews confirming deficiencies and expectations. |
| SSD | Social Service Director | Interviewed regarding transfer/discharge and dental care follow-up. |
| SSA | Social Service Assistant | Interviewed regarding dental care follow-up and communication. |
| Administrator | Interviewed regarding transfer/discharge and dental care communication. | |
| CNA II | Certified Nursing Assistant | Observed with improper mask use. |
| Unit Clerk QQ | Involved in dental appointment scheduling and communication. | |
| Unit Clerk SS | Observed with improper mask use. | |
| Staffing Coordinator | Observed with improper mask use. |
Inspection Report
Routine
Census: 90
Deficiencies: 12
Date: Dec 9, 2023
Visit Reason
A standard survey was conducted from December 5 through December 9, 2023, including investigation of multiple complaint intake numbers, some substantiated with deficiencies.
Complaint Details
Complaint Intake Numbers GA00240102, GA00235928, GA00240910, GA002377311, GA00238909, GA00240128, and GA239887 were investigated. GA00235928 and GA00240910 were unsubstantiated. GA002377311 was substantiated with no deficiencies. GA00240102, GA00238909, GA00240128, and GA239887 were substantiated with deficiencies.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies in privacy/confidentiality, notice requirements before transfer/discharge, preparation for safe discharge, bed hold policy notification, care plan implementation, discharge summary completion, treatment to maintain hearing/vision, respiratory care, medication administration, dental services, infection prevention and control, and antibiotic stewardship.
Deficiencies (12)
Privacy breach by posting clinical information on resident's door and visible EMR screens.
Failure to provide written notice of transfer/discharge and discharge summary to residents and representatives.
Failure to document preparation and orientation for safe and orderly discharge for one resident.
Failure to notify residents of bed-hold policy in writing prior to transfer for two residents.
Failure to implement comprehensive person-centered care plan related to dental services for one resident.
Failure to complete discharge summary including recapitulation of stay, medication reconciliation, and post-discharge plan for one resident.
Failure to ensure proper treatment and assistive devices to maintain hearing and vision for one resident.
Failure to administer oxygen therapy according to physician orders and lack of proper oxygen equipment use for two residents.
Medication error rate of 15.38% with errors in medication administration for three residents.
Failure to timely refer one resident to oral surgeon as recommended by contracted dentist.
Failure to maintain proper infection control related to storage of personal care items and serving food to residents in isolation.
Failure to establish an antibiotic stewardship program including monitoring and feedback for antibiotic use for four residents.
Report Facts
Census: 90
Medication error rate: 15.38
Medication errors: 4
Residents sampled: 52
Residents with infection control issues: 11
Residents with antibiotic stewardship issues: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Certified Medication Aide | Named in medication administration errors and confidentiality breach |
| GG | Licensed Practical Nurse / Unit Manager | Named in oxygen administration and medication administration errors |
| HH | Licensed Practical Nurse | Named in medication administration errors |
| SSD | Social Service Director | Named in discharge planning and dental referral deficiencies |
| DON | Director of Nursing | Named in multiple deficiencies including confidentiality, discharge, oxygen administration, infection control |
| Unit Clerk | Named in dental referral follow-up deficiencies | |
| CNA II | Certified Nursing Assistant | Named in infection control and mask use deficiencies |
Inspection Report
Life Safety
Census: 92
Capacity: 119
Deficiencies: 5
Date: Dec 6, 2023
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with fire safety and life safety requirements under 42 CFR Subpart 483.909(a) and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements due to multiple deficiencies including failure to maintain emergency lighting, missing drywall in hazardous mechanical room smoke partitions, lack of sprinkler protection at the rear overhang storage area, exit doors that would not self-close and latch properly, and unsealed penetrations above the ceiling at the main hallway smoke compartment.
Deficiencies (5)
Failed to maintain emergency lighting throughout the facility, including medicine room, rear room 33, right side 7 and 8, and exterior multi-emergency lights.
Failed to maintain smoke partitions in hazardous mechanical room; drywall missing and in need of repair and sealing.
Failed to install sprinkler protection at the outside rear overhang with storage.
Exit doors at FD connection, room 8, and break room would not self-close and latch properly.
Failed to seal penetrations above ceiling at smoke compartment of main hallway; improper material/foam packed into damaged exterior brick wall needing repair and sealing.
Report Facts
Census: 92
Total Capacity: 119
Residents at risk due to sprinkler deficiency: 20
Residents at risk due to exit door deficiency: 50
Residents at risk due to smoke barrier deficiency: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who accompanied surveyor during facility tour and confirmed findings |
Inspection Report
Abbreviated Survey
Census: 90
Deficiencies: 0
Date: Oct 24, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00240046 from October 18, 2023 to October 24, 2023.
Complaint Details
Complaint #GA00240046 was investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 5, 2023
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00235074.
Complaint Details
Complaint #GA00235074 was unsubstantiated.
Findings
The complaint #GA00235074 was investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Census: 93
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited during a prior complaint survey concluded on May 2, 2023.
Findings
All deficiencies cited as a result of the complaint survey were found to be corrected during the revisit survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 2, 2023
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00234634 regarding an allegation of physical abuse between two residents.
Complaint Details
Complaint GA00234634 was substantiated. The investigation revealed a resident-to-resident altercation on 3/26/2023 where R#5 slapped R#4. The incident was reported late to the Administrator on 3/29/2023. The charge nurse knew the Administrator was the abuse coordinator but forgot to notify her immediately.
Findings
The facility failed to ensure timely reporting of an allegation of physical abuse involving two residents to the State Agency and the facility Abuse Coordinator. The incident involved a resident-to-resident altercation where one resident slapped another, and the charge nurse failed to notify the Administrator immediately as required.
Deficiencies (1)
Failure to ensure that an allegation of physical abuse was reported to the State Agency in a timely manner for two residents.
Report Facts
Date of incident: Mar 26, 2023
Date incident reported to Administrator: Mar 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant | Reported the incident to the Resident Ambassador | |
| Registered Nurse Charge Nurse | Notified of the incident, separated residents, but forgot to notify Administrator | |
| Administrator | Abuse coordinator who was notified late and reported incident to State Agency |
Inspection Report
Deficiencies: 0
Date: Apr 19, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for University Nursing & Rehab Center following a survey completed on April 19, 2023.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies in the provided page.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 19, 2023
Visit Reason
A health revisit survey was conducted on April 19, 2023, in conjunction with investigations of Complaint Intake Numbers GA00232789 and GA00234173.
Complaint Details
Complaint Intake Numbers GA00232789 and GA00234173 were investigated and found to be unsubstantiated.
Findings
All deficiencies cited as a result of the 2/23/2023 Complaint Investigation and a COVID-19 Survey were found to be corrected. The complaint investigation found both complaints were unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 19, 2023
Visit Reason
A revisit survey was conducted on April 19, 2023, in conjunction with investigation of Complaint Intake Numbers GA00232789 and GA00234173.
Complaint Details
Complaint Intake Numbers GA00232789 and GA00234173 were investigated and found to be unsubstantiated.
Findings
All deficiencies cited as a result of the 2/23/2023 Complaint Investigation and a COVID-19 Survey were found to be corrected. The complaint investigation found both complaints were unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 23, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted in conjunction with a Focused Infection Control Survey investigating multiple complaints received against the facility between February 20 and February 23, 2023.
Complaint Details
The survey investigated multiple complaints (GA00232219, GA00228214, GA00229866, GA00231468, GA00231287, GA00231602, GA00228842, GA00231597, GA00229834, GA00232260, GA00231071, GA00228921, GA00228817, GA00231210, and GA00232524). Complaints GA00228214, GA00229866, GA00231468, GA00231602, GA00228842, GA00231597, GA00232260, GA00231071, GA00228817, GA00231210, and GA00232524 were unsubstantiated. Complaints GA00228921, GA00232219, and GA00229834 were substantiated with no deficiencies. Complaint GA00231287 was substantiated with deficiencies.
Findings
The facility was found to have deficiencies related to failure to implement care plans for personal hygiene for one resident, failure to accurately document daily wound care for one resident with a stage four pressure wound, and failure to ensure accurate medication administration documentation for two residents. Some complaints were substantiated with deficiencies, while others were unsubstantiated or substantiated with no deficiencies.
Deficiencies (3)
Failed to implement the plan of care for baths and/or personal hygiene for one resident (R#4).
Failed to ensure licensed nursing staff accurately documented daily wound care for one resident (R#19) with a stage four pressure wound.
Failed to ensure accurate documentation of medication administration for two residents (R#4 and R#19), including missed entries on medication administration records and treatment administration records.
Report Facts
Missed medication administration entries: 18
Missed wound treatment documentation: 18
Number of complaints investigated: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) DD | Interviewed regarding shower team procedures and resident R#4's shower refusals. | |
| LPN BB | Wound Care Licensed Practical Nurse | Interviewed regarding wound care treatments and documentation for resident R#19. |
| LPN AA | Licensed Practical Nurse | Interviewed regarding medication administration procedures and documentation. |
| Director of Nursing (DON) | Interviewed regarding wound care scheduling, medication documentation concerns, and facility corrective actions. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Feb 20, 2023
Visit Reason
The inspection was a State Licensure survey conducted from February 20, 2023 through February 23, 2023 to determine compliance with the State Long Term Care Requirements.
Findings
The facility failed to ensure licensed nursing staff accurately documented daily wound care for one resident with a stage four pressure wound and failed to implement a plan of care for baths and personal hygiene for another resident. Additionally, the facility did not ensure accurate documentation of medication administration for hypertensive medications for one resident and wound treatment documentation for another.
Deficiencies (4)
Failure to accurately document daily wound care for resident #19 with a stage four pressure wound.
Failure to implement a plan of care for baths and personal hygiene for resident #4.
Failure to accurately document medication administration for hypertensive medications for resident #4.
Failure to maintain accurate treatment documentation for wound care for resident #19.
Report Facts
Missed medication documentation entries: 20
Missed wound treatment documentation entries: 19
Resident shower refusals: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Wound Care Licensed Practical Nurse | Interviewed regarding wound care treatments and documentation for resident #19. |
| LPN AA | Licensed Practical Nurse | Interviewed regarding medication administration procedures and documentation. |
| CNA DD | Certified Nursing Assistant | Interviewed regarding shower team procedures and resident #4's shower refusals. |
| Director of Nursing (DON) | Interviewed regarding wound care scheduling, medication documentation concerns, and plans of correction. |
Inspection Report
Deficiencies: 0
Date: Sep 8, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for University Nursing & Rehab Center following a state inspection.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 93
Deficiencies: 0
Date: Sep 8, 2022
Visit Reason
A revisit survey was conducted on 9/8/22 to verify correction of deficiencies cited in the 6/20/22 Recertification Survey. Additionally, a complaint investigation (Complaint Intake Number GA00225326) was conducted in conjunction with this revisit survey.
Complaint Details
Complaint Intake Number GA00225326 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the prior 6/20/22 Recertification Survey were found to be corrected. The complaint investigation found Complaint Intake Number GA00225326 to be unsubstantiated.
Report Facts
Census: 93
Inspection Report
Re-Inspection
Census: 93
Deficiencies: 0
Date: Sep 8, 2022
Visit Reason
A revisit survey was conducted on 9/8/22 to verify correction of deficiencies cited in the 6/20/22 Recertification Survey. Additionally, a complaint investigation (Complaint Intake Number GA00225326) was conducted in conjunction with this revisit.
Complaint Details
Complaint Intake Number GA00225326 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected. The complaint investigation was unsubstantiated.
Report Facts
Census: 93
Inspection Report
Renewal
Census: 94
Deficiencies: 2
Date: Jun 20, 2022
Visit Reason
The inspection was a Licensure Survey conducted from June 13, 2022 through June 20, 2022 to assess compliance with state licensure requirements.
Findings
The facility failed to ensure medication carts were locked when unattended during medication administration and failed to provide adequate assistance with activities of daily living, specifically nail care, for three residents. Multiple interviews and observations confirmed these deficiencies.
Deficiencies (2)
The facility failed to ensure that one of three medication carts was locked and secure when out of view of the nurse during medication administration.
The facility failed to provide assistance with activities of daily living care related to nail care for three residents (R#3, R#10, R#42).
Report Facts
Census: 94
Residents with ADL care deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MM | Licensed Practical Nurse (LPN) | Named in medication cart security deficiency |
| DDD | Licensed Practical Nurse (LPN) | Confirmed resident R#10's nails were very long and trimmed them |
| FFF | Certified Nursing Assistant (CNA) | Stated resident R#10 did not reject care and tried to trim nails |
| HHH | Certified Nursing Assistant (CNA) | Interviewed regarding residents R#3 and R#42 nail care and refusal |
| EE | Nurse Practitioner (NP) | Confirmed resident R#10's nails were long and dirty and discussed care rejection documentation |
| MMM | Certified Nursing Assistant (CNA) | Stated resident R#42 never rejected care and tried to trim nails |
| Director of Nursing (DON) | Director of Nursing | Stated expectation that medication carts be locked when unattended |
| Administrator | Administrator | Stated expectation that medication carts be locked when unattended and discussed nail care expectations |
Inspection Report
Routine
Census: 94
Deficiencies: 8
Date: Jun 20, 2022
Visit Reason
A standard survey was conducted at University Nursing and Rehab Center from 6/13/2022 through 6/20/2022, including investigation of multiple complaint intake numbers.
Complaint Details
Complaint Intake Numbers GA00221176, GA00221872, GA00221168, GA00224047, GA00224435 were investigated in conjunction with this standard survey. GA00221872 was substantiated with citations and all other complaints were unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, including failure to honor residents' advance directives regarding CPR for four residents, failure to ensure code status orders were documented and followed, failure to provide timely Notice of Medicare Noncoverage and Skilled Nursing Facility Advance Beneficiary Notice, failure to complete comprehensive assessments timely, failure to coordinate PASRR level II reviews after mental health status changes, failure to provide adequate assistance with nail care for dependent residents, failure to provide CPR to full code residents who expired, failure to ensure dialysis communication and assessments, and failure to secure medication carts properly.
Deficiencies (8)
Failed to honor residents' advance directives by not performing CPR for four full code residents who expired.
Failed to provide Notice of Medicare Noncoverage and Skilled Nursing Facility Advance Beneficiary Notice timely to residents.
Failed to complete comprehensive assessments within 14 days of admission for three residents.
Failed to coordinate PASRR level II reviews after significant change in mental health status for two residents.
Failed to provide assistance with nail care for three dependent residents.
Failed to provide CPR to four full code residents who expired, resulting in immediate jeopardy.
Failed to ensure pre and post dialysis assessments and communication with dialysis center for one resident.
Failed to ensure medication cart was locked and secure when not in view during medication administration.
Report Facts
Residents with full code status: 68
Residents expired without CPR: 4
Residents reviewed for nail care: 7
Facility employees educated on CPR and advanced directives: 65
Contract staff educated on CPR and advanced directives: 33
Residents reviewed for PASRR coordination: 2
Residents reviewed for dialysis communication: 1
Residents census on 6/13/2022: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN JJ | Licensed Practical Nurse | Provided skilled note for resident R#243 on 2/21/2022 and described events related to resident's death. |
| RN BB | Registered Nurse | Hospice nurse who pronounced resident R#243 deceased and stated facility should have known code status. |
| LPN VV | Licensed Practical Nurse | Found resident R#141 without vital signs and thought resident was DNR due to hospice. |
| DON | Director of Nursing | Provided multiple interviews regarding facility policies and expectations on CPR and code status. |
| Administrator | Provided interviews regarding facility policies and expectations on CPR and medication cart security. | |
| LPN FF | Licensed Practical Nurse | Provided care for resident R#85 and described dialysis communication and monitoring. |
| RN JJJJ | Registered Nurse | Described dialysis schedule and communication for resident R#85. |
| LPN NN | Licensed Practical Nurse | Described dialysis communication issues for resident R#85. |
| LPN KKKK | Licensed Practical Nurse | Described monitoring of resident R#85's fistula and permacath. |
| LPN MM | Licensed Practical Nurse | Observed leaving medication cart unlocked during medication administration. |
| CNA FFF | Certified Nursing Assistant | Reported resident R#10 did not reject nail care and tried to trim nails during bathing. |
Inspection Report
Life Safety
Census: 90
Capacity: 122
Deficiencies: 0
Date: Jun 17, 2022
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and fire safety standards.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR § 483.73, Life Safety from Fire, and the NFPA 101 Life Safety Code 2012 edition.
Inspection Report
Deficiencies: 0
Date: May 4, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for University Nursing & Rehab Center following a survey completed on May 4, 2022.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Census: 89
Deficiencies: 0
Date: May 4, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the complaint survey on 2022-02-24.
Complaint Details
The revisit survey was conducted following a complaint survey on 2/24/2022; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 2/24/2022 complaint survey were found to be corrected during the revisit survey.
Report Facts
Census: 89
Inspection Report
Renewal
Deficiencies: 2
Date: Feb 24, 2022
Visit Reason
A Licensure Survey was conducted from 1/18/22 through 2/24/22 to assess compliance with licensure requirements for the facility.
Findings
The facility failed to obtain physician orders for weekly dressing changes and proper administration of intravenous medications for one resident with a PICC line. Additionally, the facility failed to provide evidence that one resident was offered and received pneumococcal or influenza vaccines as required.
Deficiencies (2)
Failure to obtain physician's order for weekly dressing changes to a PICC line and failure to administer intravenous medication and flushes as ordered for one resident.
Failure to provide evidence that one resident was offered and received pneumococcal or influenza vaccines.
Report Facts
Physician Orders missing: 1
Residents reviewed for immunizations: 5
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | LPN wound care nurse | Interviewed regarding PICC line dressing changes and documentation. |
| HH | Pharmacist | Interviewed regarding PICC line dressing frequency. |
| GG | RN weekend supervisor | Interviewed about IV antibiotic administration and PICC line use. |
| DON | Director of Nursing | Interviewed regarding PICC line dressing changes and medication administration records. |
| Infection Control Preventionist | ICP | Interviewed regarding immunization records and vaccine offerings for resident #8. |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 6
Date: Feb 24, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating multiple complaint intakes. The visit was to investigate complaints related to infection control and care practices.
Complaint Details
Complaints GA00215155 and GA00217683 were unsubstantiated. Complaint GA00214234 was substantiated without deficiencies. Complaints GA00217727 and GA00220853 were substantiated with deficiencies related to infection control and care.
Findings
The facility was found not to be in compliance with infection control regulations. Deficiencies included failure to provide catheter care as ordered, failure to administer physician-ordered IV antibiotics, failure to obtain physician orders for PICC line care and dressing changes, failure to provide appropriate laboratory monitoring for vancomycin, failure to offer and document influenza and pneumococcal immunizations, and failure to provide timely COVID-19 vaccination doses.
Deficiencies (6)
Failure to follow care plan for indwelling catheter care and failure to administer physician ordered antibiotic for one resident.
Failure to obtain physician's order for weekly PICC line dressing changes and failure to administer IV medication and flushes as ordered.
Failure to provide evidence of catheter care for one resident with indwelling catheter.
Failure to obtain vancomycin trough levels as ordered for one resident.
Failure to provide evidence that one resident was offered and received pneumococcal or influenza vaccine.
Failure to ensure one resident received a second dose of COVID-19 vaccine in a timely manner.
Report Facts
Facility census: 80
Vancomycin trough level: 18.8
Medication doses missed: 9
Resident BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN GG | Weekend Supervisor | Interviewed regarding IV antibiotic administration and vancomycin trough levels |
| LPN CC | Wound Care Nurse | Interviewed regarding PICC line dressing changes |
| Pharmacist HH | Interviewed regarding vancomycin trough levels and medication orders | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding PICC line dressing changes and medication administration |
| Infection Control Preventionist (ICP) | Infection Control Preventionist | Interviewed regarding immunizations and COVID-19 vaccination status |
| Physician MM | Physician | Interviewed regarding care of resident #1 |
| CNA JJ | Certified Nursing Assistant | Interviewed regarding catheter care and resident assistance |
Inspection Report
Abbreviated Survey
Census: 89
Deficiencies: 0
Date: Dec 22, 2020
Visit Reason
An Abbreviated/Partial Extended Survey in conjunction with a COVID-19 Focused Infection Control Survey was conducted to investigate complaints #GA00210524, #GA00210557, and #GA00210558.
Complaint Details
Complaints #GA00210524, #GA00210557, and #GA00210558 were investigated and found to be unsubstantiated with no regulatory violations.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and 42 CFR 483.80 infection control regulations. Complaints were unsubstantiated with no regulatory violations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 12, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00203577, #GA00205038, and #GA00205776.
Complaint Details
Complaint GA00203577 was substantiated with no deficiencies. Complaint GA00205038 was not substantiated. Complaint GA00205776 was substantiated with no deficiencies.
Findings
Complaint GA00203577 was substantiated with no deficiencies, complaint GA00205038 was not substantiated, and complaint GA00205776 was substantiated with no deficiencies.
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 0
Date: Oct 20, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the Infection Control Focused Survey conducted on 2020-07-24.
Findings
All deficiencies cited in the previous Infection Control Focused Survey were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 0
Date: Oct 20, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in a prior Infection Control Focused Survey dated 6/16/2020.
Findings
All deficiencies cited in the previous Infection Control Focused Survey were found to be corrected during this revisit survey.
Report Facts
Census: 87
Inspection Report
Routine
Census: 88
Deficiencies: 1
Date: Aug 12, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on August 11-12, 2020 by Ascellon on behalf of the Georgia Department of Community Health (DCH).
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulation, with one deficiency related to COVID-19 Focused Infection Control Survey noncompliance.
Deficiencies (1)
Deficiency related to the COVID-19 Focused Infection Control Survey noncompliance
Report Facts
Total census: 88
Inspection Report
Routine
Census: 94
Deficiencies: 1
Date: Jul 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations, specifically related to COVID-19 screening and prevention measures.
Findings
The facility was found not in compliance with infection control regulations due to failure to ensure all employees were adequately screened for COVID-19 symptoms upon entering the building. Discrepancies were found between staff working and those completing screening logs, and staff screening was inconsistently monitored.
Deficiencies (1)
Failure to ensure all employees were adequately screened for signs and symptoms of COVID-19 when entering the building.
Report Facts
Census: 94
COVID positive residents: 6
Staff COVID positive: 8
Staff worked vs screened: 36
Staff screened: 31
Staff not completing screening: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse (LPN) | Conducted temperature check and screening for surveyor; also filled in for receptionist conducting screening |
| AA | Certified Nursing Assistant (CNA) | Mentioned in relation to screening practices and missing from screening log on 7/23/2020 |
| BB | Certified Nursing Assistant (CNA) | Mentioned regarding self-screening practices and missing from screening log on 7/23/2020 |
| Administrator | Provided census and COVID positive resident/staff data; completed screening log during survey | |
| Infection Control Preventionist (ICP) | Monitors screening logs and follows up on screening issues | |
| Director of Nursing (DON) | Provided information on screening procedures and monitoring |
Inspection Report
Abbreviated Survey
Census: 95
Deficiencies: 1
Date: Jun 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on June 16, 2020, to assess compliance with infection prevention and control requirements during the COVID-19 pandemic.
Findings
The facility was found not in substantial compliance with Medicare regulations related to infection prevention and control. Specifically, staff failed to practice social distancing during breaks, with multiple staff observed wearing masks improperly or not at all and sitting less than six feet apart.
Deficiencies (1)
Failure to ensure staff practiced social distancing during breaks with masks off, observed during a COVID-19 pandemic.
Report Facts
Census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator #1 | Observed not practicing social distancing and wearing mask improperly during break | |
| MDS Coordinator #2 | Observed not practicing social distancing and wearing mask improperly during break | |
| Administrator | Administrator | Interviewed and instructed staff to practice social distancing and sit one per table |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 11, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints identified by codes GA00199267, GA00199671, GA00200689, GA00202435, GA00202700, and GA00202821.
Complaint Details
The complaints investigated were unsubstantiated with no deficiencies.
Findings
The complaints investigated during the survey were found to be unsubstantiated and no deficiencies were identified.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 10, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints identified by codes GA00199267, GA00199671, GA00200689, GA00202435, and GA00202700.
Complaint Details
The complaints GA00199267, GA00199671, GA00200689, GA00202435, and GA00202700 were investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaints investigated during the survey were unsubstantiated and no deficiencies were found.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 29, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 29, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.
Inspection Report
Re-Inspection
Census: 97
Deficiencies: 0
Date: Mar 27, 2019
Visit Reason
A revisit was conducted on March 27, 2019 to verify correction of deficiencies cited during the February 7, 2019 Standard Survey.
Findings
All deficiencies cited as a result of the February 7, 2019 Standard Survey were found to be corrected.
Inspection Report
Re-Inspection
Census: 97
Deficiencies: 0
Date: Mar 27, 2019
Visit Reason
A revisit was conducted to verify correction of deficiencies cited during the February 7, 2019 Standard Survey.
Findings
All deficiencies cited in the prior February 7, 2019 Standard Survey were found to be corrected during this revisit.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 12, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00195201 from March 11, 2019 to March 12, 2019.
Complaint Details
Complaint GA00195201 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were found during the survey.
Inspection Report
Routine
Census: 95
Deficiencies: 4
Date: Feb 7, 2019
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to address resident complaints about bed linen changes and food quality, provision of stained and insufficient linens, storage of expired medications, and serving food that was unpalatable and improperly prepared.
Deficiencies (4)
Failure to implement effective resolutions to resident complaints regarding bed linen changes and food quality.
Failure to provide clean, comfortable, and homelike environment due to stained, dingy, and insufficient bed and bath linens.
Failure to remove expired medications from medication storage room.
Failure to ensure food was palatable, attractive, and prepared to conserve nutritive value and flavor.
Report Facts
Resident census: 95
Expired nutritional supplement bottles: 18
Expired antacid bottles: 1
Residents interviewed in Resident Council Meeting: 10
Wash cloths stained in laundry room: 10
Clean wash cloths available in facility: 14
Residents sampled: 39
Residents eating 25% or less of okra with tomatoes: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LL | Unit Nurse Manager | Named in relation to bed linen change complaints and medication storage |
| AA | Licensed Practical Nurse | Named in relation to linen condition and medication storage |
| DD | Regional Nurse Consultant | Confirmed lack of process to validate effectiveness of complaint resolutions |
| RD | Registered Dietitian | Named in relation to food quality complaints and menu changes |
| DM | Dietary Manager | Named in relation to food quality complaints and menu responses |
Inspection Report
Routine
Deficiencies: 1
Date: Feb 7, 2019
Visit Reason
The inspection was conducted to evaluate compliance with pharmacy management and administration regulations, specifically focusing on medication storage and removal of expired medications.
Findings
The facility failed to remove expired medications from one of two medication storage rooms, including expired nutritional supplements and antacid bottles. Interviews confirmed that expired medications were not identified during the last monthly check but were not administered to residents.
Deficiencies (1)
The facility failed to remove expired medications from one of two medication storage rooms, including 18 bottles of Glucerna Therapeutic Nutritional supplement expired September 2018 and one bottle of Geri-Max Regular strength antacid expired October 2018.
Report Facts
Expired medication count: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN LL | Unit Manager Licensed Practical Nurse | Responsible for checking medication room and medication carts for expired medications; confirmed expired medications found during inspection |
| LPN AA | Licensed Practical Nurse | Interviewed during medication room inspection regarding expired medication removal process |
Inspection Report
Life Safety
Census: 95
Capacity: 122
Deficiencies: 2
Date: Feb 5, 2019
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with 42 CFR Subpart 483.70(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to maintain smoke barriers with a ½ hour fire resistance rating and failure to provide proper materials for the designated smoking area, which could place residents at risk.
Deficiencies (2)
Failed to maintain smoke barriers to maintain a ½ hour fire resistant rating due to a penetration above the ceiling at the smoke stop at room 40 not properly fire stopped where 2 cables penetrate the wall.
Failed to provide proper materials for the designated smoking area; specifically, the smoking area did not have ashtrays of non-combustible material and safe design.
Report Facts
Census: 95
Total Capacity: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Life Safety
Census: 95
Capacity: 122
Deficiencies: 2
Date: Feb 5, 2019
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, specifically failing to maintain smoke barriers with a ½ hour fire resistance rating and failing to provide proper materials for the designated smoking area, which could place residents at risk.
Deficiencies (2)
Failed to maintain smoke barriers to maintain a ½ hour fire resistant rating due to a penetration above the ceiling at the smoke stop at room 40 not properly fire stopped where 2 cables penetrate the wall.
Failed to provide proper materials for the designated smoking area; specifically, the smoking area lacked ashtrays of non-combustible material and safe design.
Report Facts
Census: 95
Total Capacity: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 16, 2019
Visit Reason
A Revisit Survey for an Abbreviated/Partial Extended Survey was conducted related to complaint #GA00192974 to verify correction of previous deficiencies.
Complaint Details
This was a complaint-related revisit survey for complaint #GA00192974.
Findings
The survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of January 13, 2019.
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 2
Date: Nov 29, 2018
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00192974 regarding insulin administration and care plan compliance.
Complaint Details
The investigation was initiated due to complaint GA00192974 concerning insulin administration errors. The complaint was substantiated as the facility failed to administer insulin as ordered for two residents.
Findings
The facility failed to ensure that two residents (R "A" and R#5) of four reviewed for insulin were administered insulin as ordered by the physician, with multiple instances of inaccurate dosages or missed doses documented in November 2018. The Director of Nursing confirmed these failures during the review.
Deficiencies (2)
Failure to develop and implement a comprehensive care plan ensuring insulin administration as ordered.
Failure to provide quality care by administering insulin accurately according to physician orders.
Report Facts
Resident census: 98
Insulin administration errors for Resident A: 7
Opportunities for Novolog sliding scale insulin administration for Resident A: 113
Opportunities for scheduled Novolog insulin doses for Resident A: 85
Opportunities for Basaglar insulin administration for Resident A: 28
Insulin administration errors for Resident #5: 6
Opportunities for Novolog sliding scale insulin administration for Resident #5: 113
Opportunities for scheduled Novolog insulin doses for Resident #5: 85
Opportunities for Lantus insulin administration for Resident #5: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse AA | Licensed Practical Nurse | Described medication reconciliation and insulin administration competency checks |
| Director of Nursing | Director of Nursing | Confirmed failures in insulin administration and reviewed MARs for residents |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 29, 2018
Visit Reason
The inspection was conducted to investigate complaints related to insulin administration for two residents at University Nursing & Rehab Center, focusing on whether insulin was administered as ordered by the physician.
Complaint Details
The investigation was complaint-related, focusing on insulin administration errors for residents R "A" and R#5. The Director of Nursing confirmed that licensed nursing staff failed to administer the accurate amount of Novolog Insulin per the ordered sliding scale and routine scheduled insulins as ordered.
Findings
The facility failed to ensure that two residents received insulin as ordered, with multiple instances of inaccurate dosages and missed administrations documented in the Medication Administration Records. Despite these errors, no complications related to insulin misadministration were reported for the residents.
Deficiencies (1)
Failure to administer insulin as ordered for two residents, including inaccurate dosages and missed doses.
Report Facts
Sample size: 5
Residents reviewed for insulin errors: 4
Residents with insulin administration failures: 2
Insulin dosage errors: 14
Insulin dosage errors: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed and confirmed insulin administration failures |
| Licensed Practical Nurse AA | Licensed Practical Nurse (LPN) | Interviewed regarding insulin administration procedures and competency |
Inspection Report
Abbreviated Survey
Census: 97
Deficiencies: 0
Date: Apr 26, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00187597 at University Nursing and Rehabilitation Center.
Complaint Details
Investigation of complaint GA00187597; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Report Facts
Facility census: 97
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 15, 2018
Visit Reason
The inspection was conducted to investigate complaint #GA00185214 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00185214 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey conducted from 2/14/18 through 2/15/18.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 8, 2018
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Routine
Census: 91
Deficiencies: 0
Date: Dec 22, 2017
Visit Reason
A standard survey was conducted at University Nursing and Rehabilitation Center from December 19, 2017 through December 22, 2017 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The standard survey revealed that the facility was in compliance with the Health portion of the Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 91
Capacity: 122
Deficiencies: 9
Date: Dec 19, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with several Life Safety Code requirements including emergency preparedness plan deficiencies, fire extinguisher notifications, smoke detector installation, sprinkler system installation and maintenance, electrical system maintenance, and smoking area safety. Multiple deficiencies could place residents and staff at risk in the event of an emergency or fire.
Deficiencies (9)
Emergency Preparedness Plan not in substantial compliance with Appendix Z; missing elements include emergency lighting, temperature control, sewage and waste removal, and hazard risk assessment.
No training or testing has occurred for volunteers on the Emergency Preparedness Plan.
No training or testing has occurred for staff on the Emergency Preparedness Plan.
No instruction placard for the Class K fire extinguisher in the kitchen.
Lobby smoke detector improperly mounted in the air flow stream of an HVAC supply.
Fire sprinkler system installation deficiencies including heads installed outside their listing, unprotected closet in DON's office, wet sprinkler piping inside cooler not protected from freezing and leaking.
Fire sprinkler system maintenance deficiencies including painted sprinkler heads in dining room and corroded, dust-loaded sprinkler heads in kitchen.
Electrical system maintenance deficiencies including flexible cord ran through ceiling, exposed Romex wiring in DON's office closet, and extension cord used as permanent wiring in classroom.
Smoking area ashtrays are combustible rather than noncombustible as required.
Report Facts
Residents at risk: 92
Census: 91
Total licensed capacity: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews. |
Inspection Report
Abbreviated Survey
Census: 90
Deficiencies: 0
Date: Sep 21, 2017
Visit Reason
An abbreviated survey was conducted to investigate Complaint #GA00178241 and #GA00179960 at University Nursing and Rehab Center.
Complaint Details
Complaint #GA00178241 and #GA00179960 were investigated and substantiated, but no deficiencies were cited.
Findings
The complaint was substantiated although no deficiencies were cited, and the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 3, 2017
Visit Reason
The inspection was conducted as a Complaint Survey to investigate complaints #GA 00176683 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA 00176683 was investigated and found to have no deficiencies cited.
Findings
No deficiencies were cited during the complaint survey at University Nursing and Rehab Center.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 2, 2017
Visit Reason
A Health Revisit was conducted on March 1-2, 2017 in conjunction with an Abbreviated Survey to investigate complaints GA00171531 and GA00170534.
Complaint Details
Complaints GA00171531 and GA00170534 were investigated and found not substantiated.
Findings
The complaints were not substantiated and it was determined that the deficiencies cited during the Standard Survey of 11/3/16 had been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 2, 2017
Visit Reason
The inspection was conducted to investigate complaints #GA00170534 and GA171531 and to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
The visit was complaint-related, investigating complaints #GA00170534 and GA171531. No deficiencies were found, indicating no substantiated issues.
Findings
No deficiencies were cited during the complaint survey conducted at University Nursing and Rehab.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 21, 2016
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey deficiencies had been corrected.
Findings
The surveyor noted that all previously cited survey tags had been corrected during this follow-up survey.
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