Inspection Reports for University Park Nursing and Rehabilitation Center
233 University Avenue, Des Moines, IA, 503143124
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 28, 2025, was a complaint investigation in which the facility was found to be in substantial compliance with no deficiencies cited. Earlier inspections showed a mixed pattern with several citations related primarily to resident care issues such as nutrition and infection prevention, as well as environmental and staffing concerns. Complaint investigations were mostly unsubstantiated, though some substantiated complaints involved inadequate infection control, delayed nursing responses, and maintenance problems. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements over time, with recent investigations showing no deficiencies following earlier periods of cited issues.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
10.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
139% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
72 residents
Based on a May 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 28, 2025
Visit Reason
A complaint investigation was conducted for a facility reported incident #2645442-I on October 27-28, 2025.
Complaint Details
Complaint investigation related to incident #2645442-I; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 28, 2025
Visit Reason
A complaint investigation was conducted for complaints #2599331-C, #2597088-C, 2573978-C, and 1718060-C from August 26, 2025 to August 28, 2025.
Complaint Details
Complaint investigation for multiple complaints was conducted and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 23, 2025
Visit Reason
The document is a Plan of Correction submitted following a survey to address deficiencies and certify the facility's compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective May 23, 2025.
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 2
Date: May 7, 2025
Visit Reason
The inspection was conducted as a result of investigations of Complaints #126890-C and #128252-C from May 1, 2025 to May 7, 2025, focusing on nutritional adequacy and infection prevention and control.
Complaint Details
The visit was complaint-related based on Complaints #126890-C and #128252-C. The complaints resulted in deficiencies related to nutritional adequacy and infection prevention.
Findings
The facility failed to provide adequate nutrition by serving incomplete meals to a resident on a pureed diet and failed to follow infection prevention protocols for residents on Enhanced Barrier Precautions, including improper use of gowns, gloves, and hand hygiene for three residents with wounds.
Deficiencies (2)
Menus did not meet nutritional needs for 1 of 13 residents reviewed; Resident #6 was served only partial meal components including missing pureed vegetables and dessert.
Failure to provide appropriate infection prevention practices for 3 residents on Enhanced Barrier Precautions; staff did not wear gowns or perform proper hand hygiene during wound care, transfers, and hygiene tasks.
Report Facts
Resident census: 72
Residents reviewed for nutrition deficiency: 13
Residents with infection prevention deficiencies: 3
Dates of complaint investigation: May 1, 2025 to May 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Dietary Aide | Acknowledged serving only partial meal to Resident #6 |
| Staff B | Dietary Manager | Acknowledged error in serving size and failure to instruct Staff A properly |
| Staff C | Licensed Practical Nurse (LPN) | Observed performing wound dressing change without proper gown use |
| Staff D | Certified Nurse Assistant (CNA)/Certified Medication Assistant (CMA) | Observed transferring Resident #4 and Resident #7 without proper gown use or hand hygiene |
| Staff E | Certified Nurse Assistant (CNA) | Observed transferring Resident #4 and Resident #7 without proper gown use or hand hygiene |
| Director of Nursing (DON) | Director of Nursing | Acknowledged deficiencies and described expectations for gown use and hand hygiene |
| Stacy Soderstrum | Administrator | Stated facility expectations for meal service and infection control practices |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 20, 2025
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was certified in compliance effective February 20, 2025, based on acceptance of the Plan of Correction and credible allegation of substantial compliance. No specific deficiencies or severity levels are detailed in this document.
Inspection Report
Annual Inspection
Census: 76
Deficiencies: 7
Date: Jan 30, 2025
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of substantiated complaints and a facility reported incident from January 27 to January 30, 2025.
Complaint Details
Complaints #123469-C, #125271-C, and #125974-C were substantiated. Facility Reported Incident #124648-I was also substantiated.
Findings
The facility was found deficient in multiple areas including resident rights and dignity, safe and homelike environment maintenance, protection from misappropriation of property, accident hazards and supervision, sufficient nursing staff response times, qualified dietary staff certification, food temperature documentation, and sanitary food preparation and service.
Deficiencies (7)
Facility failed to assure residents were treated with respect and dignity, including leaving a resident exposed in his brief for an extended period and delayed assistance.
Facility failed to maintain resident living areas in good repair and provide a homelike environment, including bathroom wall and door damage.
Facility failed to ensure residents were free from misappropriation of resident property, including theft of a resident's cell phone by a staff member.
Facility failed to ensure call light was within reach for a resident and failed to respond timely to call lights, resulting in residents waiting extended periods for assistance.
Facility failed to employ a clinically qualified dietary manager with required certification.
Facility failed to document food temperatures in the kitchen prior to distribution and serving, with multiple missing temperature logs.
Facility failed to prepare, serve, and distribute food in accordance with professional standards, including placing utensils on unclean countertops, delivering uncovered drinks, and an unclean ice machine.
Report Facts
Census: 76
Call light response time: 15
Missing meal temperature logs: 37
Resident #50 call light wait time: 45
Resident #84 wait time: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Registered Nurse (RN) | Named in delayed assistance to Resident #84 |
| Staff E | Assistant Director of Nursing (ADON) | Provided statements on call light expectations and investigation of misappropriation |
| Staff F | Certified Nursing Assistant (CNA) | Terminated for theft of Resident #35's cell phone |
| Dietary Director | Dietary Manager | Newly employed, not yet certified dietary manager |
| Administrator | Provided multiple statements on facility policies and investigations |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 27, 2024
Visit Reason
The investigation of Complaints #122252-C and #122961-C was conducted from August 26, 2024 to August 27, 2024 to determine the validity of the allegations.
Complaint Details
Investigation of Complaints #122252-C and #122961-C found the allegations unsubstantiated and the facility in substantial compliance.
Findings
The allegations were found to be unsubstantiated and the facility was determined to be in substantial compliance with applicable regulations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 11, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance and will be certified effective April 11, 2024, based on the Plan of Correction submitted.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 3, 2024
Visit Reason
A complaint investigation for complaints #119821-C was conducted from April 1, 2024 to April 3, 2024.
Complaint Details
Complaint investigation #119821-C was conducted and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 3
Date: Mar 21, 2024
Visit Reason
The inspection was conducted as an annual recertification survey of University Park Nursing & Rehabilitation Center from March 18 to March 21, 2024.
Findings
The facility was found deficient in multiple areas including failure to notify the Long Term Care Ombudsman of resident discharges/transfers, failure to provide respiratory care consistent with physician orders, and failure to maintain infection prevention and control practices such as proper hand hygiene, glove use, and catheter care.
Deficiencies (3)
Failure to notify the Long Term Care Ombudsman of discharge/transfer of residents as required for 5 of 5 residents reviewed.
Failure to ensure respiratory care was provided according to physician orders, including providing oxygen without an order and not changing oxygen tubing for 1 resident.
Failure to maintain infection prevention and control practices including hand hygiene, glove changing, and use of barriers during catheter drainage and incontinence care for 3 residents.
Report Facts
Residents reviewed for discharge notification deficiency: 5
Facility census: 79
Residents reviewed for respiratory care deficiency: 1
Residents reviewed for infection prevention deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Assistant Director of Nursing | Reported on discharge notification process and expectations for glove use and respiratory care |
| Staff D | Certified Nurse Aide | Observed failing to perform hand hygiene and proper catheter drainage procedures |
| Staff C | Environmental Services | Observed wearing gloves improperly and pushing elevator buttons |
| Staff A | Certified Nursing Assistant | Observed failing to change gloves between dirty and clean tasks during incontinence care |
| Staff B | Certified Nursing Assistant | Observed assisting with incontinence care and failing to maintain proper infection control |
| Administrator | Reported facility did not have policy for reporting to LTC Ombudsman and described reporting process |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 14, 2024
Visit Reason
A complaint investigation for complaints #118120-C and #118878-C was conducted on February 14, 2024 to February 15, 2024.
Complaint Details
Complaint investigation for complaints #118120-C and #118878-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 15, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on December 15, 2023, related to the facility's compliance status.
Findings
Based on acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance effective December 15, 2023.
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 5
Date: Nov 21, 2023
Visit Reason
The inspection was conducted based on complaints and reported incidents from November 14, 2023 to November 21, 2023, including substantiated and unsubstantiated complaints regarding resident care and facility conditions.
Complaint Details
The visit was complaint-related, investigating multiple complaints numbered 111697-C, 111956-C, 112131-C, 113986-C, 114044-C, 114626-C, 115140-C, 116040-C, and facility reported incidents 115270-I and 115263-I. Complaints 111697-C, 111956-C, 112131-C, 114044-C, 115140-C, and 116040-C were substantiated; complaints 113986-C and 114626-C were unsubstantiated; facility reported incidents 115263-I and 115270-I were unsubstantiated.
Findings
The facility was found deficient in multiple areas including failure to report significant weight loss to the physician, unsafe and unclean environment with maintenance issues, unsafe mechanical lift equipment and improper sling use, inadequate incontinence care increasing UTI risk, and insufficient nursing staff response to call lights.
Deficiencies (5)
Failure to consistently report weight loss to the physician for a resident prescribed weight-based medication.
Failure to ensure a safe, clean, and homelike environment due to damaged walls, missing paint, water stains, soiled bathroom floors, and pest issues.
Failure to ensure mechanical lifts were safe and functional, including exposed wiring and battery issues, and failure to use proper sling sizes for resident transfers.
Failure to provide proper incontinence care to minimize risk of urinary tract infections, including improper glove use and cleansing technique.
Failure to ensure sufficient nursing staff responded timely to resident call lights and met resident needs in a timely manner.
Report Facts
Resident census: 80
Weight loss percentage: 11.1
Call light response time: 15
Antibiotic order duration: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff P | Unit Manager | Reported facility paint upgrades, expected staff to notify maintenance of equipment issues, and expected timely call light responses |
| Staff A | Certified Nursing Assistant | Observed performing incontinence care and mechanical lift transfer with Resident #10 |
| Staff B | Certified Nursing Assistant | Assisted with incontinence care and mechanical lift transfer with Resident #10 |
| Staff F | Certified Nursing Assistant | Reported mechanical lifts often broken and battery issues |
| Staff H | Registered Nurse and Unit Manager | Reported maintenance notification and lock out tag out procedures for broken equipment |
| Staff E | Maintenance | Responsible for equipment repairs and maintenance, reported no preventative maintenance schedule for mechanical lifts |
| Staff L | Certified Nursing Assistant | Observed providing incontinence care to Resident #6 |
| Staff M | Certified Nursing Assistant | Observed providing incontinence care to Resident #6 |
| Staff J | Certified Nursing Assistant | Observed responding to call lights and mechanical lift use |
| Staff G | Certified Nursing Assistant | Reported procedures for mechanical lift use and battery charging |
| Staff C | Certified Nursing Assistant | Observed using improper sling size during mechanical lift transfer of Resident #13 |
| Staff D | Certified Nursing Assistant | Observed using improper sling size during mechanical lift transfer of Resident #13 |
| Staff O | Occupational Therapy | Reported therapy recommendations do not include sling size or equipment training |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 14, 2023
Visit Reason
The document is a plan of correction submitted following a prior inspection, indicating the facility's acceptance of compliance and corrective actions.
Findings
The facility was certified in compliance effective February 24, 2023, based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies or severity levels are detailed in this document.
Inspection Report
Annual Inspection
Census: 90
Deficiencies: 7
Date: Feb 2, 2023
Visit Reason
The inspection was conducted as an annual recertification survey and investigation of multiple complaints and facility reported incidents from January 30, 2023 to February 2, 2023.
Complaint Details
Complaints #108830-C, #108855-C, and #109138-C were unsubstantiated. Complaint #109138-C was substantiated. Facility reported incidents #109177-I was unsubstantiated.
Findings
The facility was found deficient in providing a safe, clean, comfortable, and homelike environment for residents, maintaining a grievance policy and process, developing and implementing baseline and comprehensive care plans, maintaining bedrails appropriately, infection prevention and control, and pest control. Several residents were affected by these deficiencies.
Deficiencies (7)
Facility failed to provide a homelike environment for 3 of 21 residents reviewed, including chipped plaster, holes in walls, and dirty stained floors.
Facility failed to establish a grievance policy to ensure prompt resolution of grievances regarding residents' rights.
Facility failed to develop and implement a baseline care plan within 48 hours of admission for 1 resident.
Facility failed to develop and implement comprehensive care plans within 7 days after completion of the comprehensive assessment for 2 residents.
Facility failed to provide and maintain bedrails appropriately, including assessment, consent, and documentation for 1 resident.
Facility failed to implement and follow appropriate infection prevention and control practices, including PPE use and hand hygiene, for 2 of 18 residents reviewed.
Facility failed to maintain an effective pest control program as evidenced by mice and mouse droppings in resident rooms.
Report Facts
Complaints investigated: 4
Residents reviewed for homelike environment: 21
Residents affected by grievance deficiency: 1
Residents reviewed for baseline care plan: 1
Residents reviewed for comprehensive care plan: 2
Residents reviewed for bedrails: 1
Residents reviewed for infection control: 2
Residents reviewed for pest control: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stacy Soderstrum | Administrator | Signed the report and plan of correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 22, 2022
Visit Reason
The document serves as a statement of deficiencies and plan of correction for University Park Nursing & Rehabilitation Center, certifying compliance based on acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility was certified in compliance effective 11/22/2022 based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 3
Date: Nov 10, 2022
Visit Reason
The inspection was conducted as a complaint survey investigating complaints #107934-C, #108039-C, and facility reported incidents #108701-1 and #108702-1 from November 1 to November 10, 2022.
Complaint Details
Complaints #107934-C and #108039-C were substantiated. Facility reported incidents #108701-1 and #108702-1 were substantiated.
Findings
The facility was found to have deficiencies in developing and implementing comprehensive care plans, ensuring adequate supervision to prevent accidents, and maintaining complete and accurate resident medical records. Complaints and incidents were substantiated involving resident care and supervision.
Deficiencies (3)
Failure to develop and implement a comprehensive care plan for Resident #1 including living history, smoking status, and wander guard usage.
Failure to ensure the resident environment remains free of accident hazards and provide adequate supervision for Residents #1 and #2.
Failure to maintain complete, accurate, and confidential medical records for Resident #2.
Report Facts
Resident census: 90
Number of residents reviewed for care plan deficiency: 3
Number of residents reviewed for supervision deficiency: 4
Number of residents reviewed for medical record deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Rodriguez | Licensed Practical Nurse (LPN) | Indicated Resident #1 had a wander guard and heard he cut it off |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 13, 2022
Visit Reason
The document reflects acceptance of the facility's credible allegation of compliance and plan of correction following an investigation ending September 8, 2022.
Findings
The facility was certified in compliance effective October 13, 2022, based on acceptance of the plan of correction and compliance allegation.
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 9
Date: Dec 20, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from 11/30/21 to 12/20/21, including investigation of complaints #98537-C, #99584-C, #100925-C, and #100913-C, which were substantiated.
Complaint Details
Investigation of complaints #98537-C, #99584-C, #100925-C, and #100913-C was conducted and substantiated during the survey.
Findings
The facility was found not in compliance with CMS and CDC recommended practices, with deficiencies including failure to provide routine baths and showers for dependent residents, insufficient nursing and dietary staff, failure to provide breakfast before dialysis for a resident, food safety violations, infection control breaches, malfunctioning call light system, and lack of maintenance for resident room lighting.
Deficiencies (9)
Facility failed to complete routine baths for 4 of 4 residents reviewed.
Facility failed to provide sufficient nursing staff to ensure 4 of 4 sampled residents received 2 showers a week.
Director of Nursing worked on the floor with census over 60 residents, contrary to regulations.
Facility failed to provide sufficient dietary staff to ensure timely meal service and dining room availability.
Facility failed to assure provision of breakfast before dialysis for 1 of 3 residents reviewed.
Facility failed to follow sanitary conditions during food service and maintain cold food at 41 degrees or lower.
Facility failed to ensure staff used infection control techniques including hand hygiene and PPE use for 2 of 13 residents reviewed.
Facility did not provide a functioning call light system throughout the facility.
Facility failed to ensure a working light in a resident's room.
Report Facts
Residents reviewed for bathing deficiencies: 4
Facility census: 90
Dates Director of Nursing worked floor: 18
Expired prune juice containers: 4
Milk temperature: 50.3
Residents reviewed for infection control: 13
Resident #11 quarantine duration: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Assistant Director of Nursing | Acknowledged missed showers and staffing issues |
| Staff M | Licensed Practical Nurse | Reported insufficient staffing and missed showers |
| Staff N | Licensed Practical Nurse | Reported use of agency CNAs unfamiliar with residents and missed showers |
| Director of Nursing | Director of Nursing | Worked on floor despite census over 60; acknowledged staffing shortages and call light issues |
| Staff J | Cook | Failed to properly sanitize thermometer during food temperature checks |
| Dietary Manager | Dietary Manager | Reported dietary staffing shortages and late meal service |
| Staff D | Certified Nursing Assistant | Failed to perform hand hygiene before, during, and after incontinence care |
| Staff C | Certified Nursing Assistant | Observed providing care without proper hand hygiene |
| Social Services Director | Social Services Director | Entered isolation room without gown or gloves |
| Staff A | Certified Nursing Assistant | Entered isolation room without gown or gloves |
| Staff H | Certified Nursing Assistant | Reported broken over bed light not fixed for weeks |
| Staff K | Certified Nursing Assistant | Reported broken over bed light to nurses |
Inspection Report
Annual Inspection
Census: 73
Deficiencies: 11
Date: Jul 12, 2021
Visit Reason
The inspection was conducted as part of the facility's annual health survey and investigation of complaints #97951 and #98137.
Complaint Details
Complaint #97951 and #98137 were investigated and found not substantiated.
Findings
The facility was found to have deficiencies including failure to maintain accurate advanced directives, unsafe and unclean environment conditions, failure to notify ombudsman of all discharges and transfers, inadequate PASARR coordination and care planning, failure to provide adequate bathing assistance, improper infection control practices, inaccurate nurse staffing postings, and failure to properly document COVID-19 vaccination consents.
Deficiencies (11)
Failure to ensure 1 of 24 active residents' advanced directives for CPR and Living Will were available and accurate (Resident #18).
Failure to maintain a safe, clean, comfortable, and homelike environment with multiple rooms requiring repairs including holes in walls, sharp edges on bathroom door, and holes in elevator flooring.
Failure to notify the ombudsman of all resident discharges, transfers, and deaths for 2 of 3 residents reviewed (Resident #26 and #27).
Failure to coordinate PASARR assessments and follow PASARR recommendations for 2 residents (Resident #49 and #62).
Failure to develop and implement comprehensive care plans addressing dialysis, catheter usage, oxygen usage, and PASARR recommendations for 4 residents (Resident #15, #46, #49, #64).
Failure to provide bathing assistance twice weekly and/or per resident preference for 5 residents (Resident #58, #64, #67, #224, #225).
Failure to prevent possible accidents by not locking the door to the dirty laundry room containing hazardous chemicals accessible to residents.
Failure to post accurate nurse staffing data in a prominent location visible to residents and visitors.
Failure to label and store food items properly to reduce risk of contamination and food-borne illness; dry storage area was unclean.
Failure to provide proper wound cleansing, ensure proper mask use by staff, maintain clean laundry room, and cover clean laundry to prevent contamination.
Failure to obtain proper consents for COVID-19 vaccinations for 2 of 5 residents reviewed (Resident #53 and #69).
Report Facts
Residents with cognitive impairment: 8
Residents reviewed for bathing assistance: 5
Residents reviewed for PASARR coordination: 2
Residents reviewed for COVID-19 vaccination consent: 2
Residents with advanced directive issue: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse | Named in wound care deficiency for improper wound cleansing |
| Staff I | Certified Nursing Assistant | Named in infection control deficiency for improper mask use |
| Staff J | Signed COVID-19 vaccine consent forms improperly for residents | |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including wound care, bathing, PASARR, and infection control |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding care plan expectations and environment deficiencies |
| Staff F | Certified Nursing Assistant | Interviewed regarding bathing schedule and practices |
| Staff B | Housekeeping Aide | Observed pushing uncovered linen cart |
| Staff A | Certified Nurse Aide | Observed improper food handling during meal preparation |
| Staff G | Maintenance Staff | Interviewed regarding facility repairs and maintenance |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 12, 2021
Visit Reason
A second revisit was conducted from May 6 to May 12, 2021 related to the investigation of multiple facility-reported incidents and complaints, including a new complaint investigated in conjunction with the revisit.
Complaint Details
Multiple complaints and facility-reported incidents were investigated, including complaint #96539-C which was not substantiated.
Findings
The facility was found in substantial compliance at the time of the revisit. The new complaint investigated was not substantiated.
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 12
Date: Apr 1, 2021
Visit Reason
The inspection was a revisit of a COVID-19 Focused Infection Control Survey and investigation of multiple facility-reported incidents and complaints conducted between March 4 and April 1, 2021.
Complaint Details
This visit was complaint-related and a revisit of a COVID-19 Focused Infection Control Survey and multiple complaints and incidents. The facility was found to have multiple deficiencies related to abuse, neglect, dignity, medication errors, and infection control. The Immediate Jeopardy identified during the investigation was lowered in scope and severity after corrective actions.
Findings
The facility was found deficient in multiple areas including resident rights and dignity, abuse and neglect policies, professional standards of care, quality of care, treatment and prevention of pressure ulcers, accident hazards supervision, medication errors, staff qualifications, infection prevention and control, and abuse training. The facility reported a census of 85 residents during the survey.
Deficiencies (12)
Facility failed to treat residents with dignity and respect, including rough handling and lack of bedside manner.
Facility failed to develop and implement policies to prevent abuse, neglect, and exploitation and to conduct background checks on new hires.
Facility failed to meet professional standards of care and follow physician orders for residents.
Facility failed to assess and treat resident pain adequately.
Facility failed to prevent and treat pressure ulcers appropriately.
Facility failed to ensure resident environment was free of accident hazards and provide adequate supervision devices.
Facility failed to ensure competent nursing staff demonstrated necessary skills and competencies.
Facility failed to verify nurse credentials upon hire.
Facility failed to maintain a quality assessment and assurance committee meeting at least quarterly.
Facility failed to establish and maintain an infection prevention and control program.
Facility failed to provide abuse, neglect, and exploitation training to staff and ensure compliance.
Facility failed to ensure residents were free from significant medication errors.
Report Facts
Census: 85
Residents reviewed: 22
Residents with medication errors: 3
Temporary nurse aides reviewed: 5
New hires reviewed for background checks: 6
Nurses reviewed for credentials: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Certified Nursing Assistant | Named in resident dignity and abuse findings. |
| Staff A | Certified Nursing Assistant | Named in background check deficiency. |
| Staff U | Certified Nursing Assistant | Named in background check deficiency. |
| Staff F | Certified Medication Aide | Named in medication error findings. |
| Staff P | Temporary Nurse Aide | Named in nurse aide competency deficiency. |
| Staff Q | Temporary Nurse Aide | Named in nurse aide competency deficiency. |
| Staff T | Temporary Nurse Aide | Named in nurse aide competency deficiency. |
| Staff B | Registered Nurse | Named in nurse credential verification deficiency. |
| Staff G | Licensed Practical Nurse | Named in nurse credential verification deficiency. |
| Staff V | Named in abuse training deficiency. | |
| Staff W | Named in abuse training deficiency. |
Inspection Report
Routine
Census: 78
Deficiencies: 0
Date: Dec 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals from 12/21/20 through 12/23/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 89
Deficiencies: 3
Date: Dec 3, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from October 22 to December 3, 2020, in conjunction with investigations of a facility-reported incident and multiple complaints.
Complaint Details
The facility-reported incident #93996-I and complaints #93211-C and #94129-C were substantiated. Complaints #93600-C, #93805-C, #9359-C, #94079-C, #94417-C, and #94427-C were not substantiated.
Findings
The facility was found to be in compliance with CDC recommended practices for COVID-19 preparation. Two facility-reported incidents and complaints were substantiated, while several other complaints were not substantiated. Deficiencies were identified related to ADL care for dependent residents, treatment services to prevent/heal pressure ulcers, and free of accident hazards/supervision devices.
Deficiencies (3)
Facility staff failed to provide routine oral care for one of five residents reviewed for grooming and hygiene assistance.
Facility failed to ensure two residents did not receive facility-acquired pressure ulcers and failed to provide necessary treatment and services to prevent and heal pressure ulcers.
Facility failed to provide safe transfer for one of five residents reviewed for nursing supervision.
Report Facts
Residents present: 89
Deficiencies cited: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 24, 2020
Visit Reason
The visit was conducted to investigate complaint #91919-C at University Park Nursing & Rehabilitation Center.
Complaint Details
Complaint #91919-C was investigated and found not substantiated.
Findings
The complaint investigation conducted from July 22 to July 24, 2020, was not substantiated.
Inspection Report
Abbreviated Survey
Census: 96
Deficiencies: 0
Date: Jul 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 96
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Date: Jul 2, 2020
Visit Reason
The inspection was conducted as a COVID-19 survey and investigation of Complaint #91529-C, which was substantiated.
Complaint Details
Complaint #91529-C was substantiated. The investigation revealed failures in infection prevention and control related to COVID-19.
Findings
The facility failed to implement recommended infection control practices to prevent the spread of COVID-19 among residents and staff, including allowing staff to work after reporting symptoms and positive tests, inadequate screening, and improper use of personal protective equipment (PPE). The facility reported an outbreak with 55 residents testing positive and 10 deaths. These findings constituted immediate jeopardy to resident health and safety.
Deficiencies (1)
Failure to implement infection control practices to prevent COVID-19 spread, including inadequate screening and PPE use.
Report Facts
Residents tested positive for COVID-19: 55
Resident deaths due to COVID-19: 10
Census: 80
Staff A overtime hours: 71.59
Staff T overtime hours: 32.67
Screening tools completed: 378
Screening tools accurately completed: 17
Staff F worked hours: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurses Aid (CNA) | Identified with symptoms and positive COVID-19 test; worked overtime while symptomatic |
| Staff B | Assistant Director of Nursing (ADON) | Reported on screening tool use and isolation practices |
| Staff E | Worked during screening period; tested positive for COVID-19 | |
| Staff F | Certified Nurses Aid (CNA) | Worked overtime; tested positive for COVID-19; reported symptoms |
| Staff T | Worked overtime; reported bringing gowns from home; tested positive for COVID-19 | |
| Staff H | Housekeeper | Observed wearing mask only; reported PPE shortages |
| Staff L | Housekeeping Manager | Reported on screening tool completion and PPE use |
| Staff U | Licensed Practical Nurse (LPN) | Reported incomplete screening tool use; tested positive for COVID-19 |
| Staff KK | Certified Nurses Aid (CNA) | Reported symptoms, testing positive for COVID-19, and PPE issues |
| Staff Y | Certified Nurses Aid (CNA) | Reported temperature checks and PPE use on unit |
| Staff HH | RN/Infection Preventionist | Reported on PPE use and infection control practices |
| Staff BB | Restorative Aide | Reported PPE availability and screening logs |
| Staff GG | Certified Nurses Aid (CNA) | Reported PPE use and thermometer availability |
| Staff V | RN/ADON | Reported PPE use and temperature screening |
| Staff M | Housekeeper | Reported lack of screening questions |
| Staff LL | Certified Nurses Aid (CNA) | Reported temperature checks and PPE use |
| Staff C | Therapy | Observed without mask or PPE |
| Staff II | Administrative Staff | Observed without mask or PPE |
| Staff Z | Certified Nurses Aid (CNA) | Reported PPE use and temperature checks |
| Staff AA | Certified Nurses Aid (CNA) | Reported quarantine procedures and PPE use |
| Staff DD | Certified Nurses Aid (CNA) | Reported PPE knowledge and screening log use |
| Staff FF | Medical Records | Reported PPE skills validation |
| Staff S | Dietary Manager | Reported PPE audits and screening procedures |
| Staff Q | Reported family notification procedures | |
| Staff D | Reported symptoms, testing positive for COVID-19, and PPE use | |
| Staff F | Reported symptoms and COVID-19 test results | |
| Staff KK | Certified Nurses Aid (CNA) | Reported symptoms, testing positive for COVID-19, and PPE use |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Date: Jun 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with the investigation of complaint #91090-C.
Complaint Details
Complaint #91090-C was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. The complaint #91090-C was unsubstantiated.
Report Facts
Total residents: 78
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 20, 2020
Visit Reason
Investigation of complaints #87460-C, #87475-C, #88481-C, and #88819-C and of facility-reported incidents #88996-I and #89177-I.
Complaint Details
Complaints #87460-C, #87475-C, #88481-C, and #88819-C and facility-reported incidents #88996-I and #89177-I were investigated and found not to result in deficiencies.
Findings
The investigation did not result in any facility deficiencies.
Report
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