Inspection Reports for
University Park Nursing and Rehabilitation Center

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.

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.

The complaint investigation found substantiated deficiencies related to nutritional service errors for Resident #6 and infection prevention failures for Residents #3, #4, and #7.

The facility failed to serve the correct portion sizes and complete meals for a resident on a pureed diet, and failed to consistently follow infection prevention protocols including gown use and hand hygiene for residents with wounds requiring Enhanced Barrier Precautions.

Complaints #123469-C, #125271-C, and #125974-C were substantiated. Facility Reported Incident #124648-I was also substantiated.

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.

The facility was found deficient in honoring residents' dignity and respect, maintaining a safe and homelike environment, protecting residents from misappropriation of property, and ensuring proper food temperature documentation. Deficiencies involved residents being left exposed, bathroom damages, theft of a resident's cell phone by a staff member, and incomplete food temperature logs.

The visit was complaint-related, triggered by allegations of dignity violations, environmental safety concerns, misappropriation of resident property, inadequate call light response, and dietary service deficiencies. The complaint was substantiated with findings of minimal harm or potential for harm.

The facility was found to have multiple deficiencies including failure to maintain resident dignity and timely assistance, failure to maintain bathrooms in good repair, failure to protect residents from misappropriation of property, failure to ensure call lights were within reach and answered timely, failure to employ a certified dietary manager, and failure to properly document and maintain food safety and sanitation standards.

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.

The facility failed to timely notify the Long Term Care Ombudsman of resident discharges or transfers for 5 residents, provided oxygen therapy without physician orders and did not change oxygen tubing as required for 1 resident, and failed to maintain proper infection control practices including hand hygiene, glove use, and sanitary catheter drainage for multiple residents. These deficiencies were associated with minimal harm or potential for harm.

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.

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.

The visit was complaint-related, triggered by concerns about medication management, environmental safety, equipment functionality, incontinence care, and staffing responsiveness. Substantiation status is not explicitly stated.

The facility was found deficient in multiple areas including failure to consistently report weight loss affecting medication dosing, unsafe and unclean environment conditions, malfunctioning mechanical lifts and improper sling use, inadequate incontinence care increasing UTI risk, and delayed response to resident call lights. The census was reported as 80 residents.

Complaints #108830-C, #108855-C, and #109138-C were unsubstantiated. Complaint #109138-C was substantiated. Facility reported incidents #109177-I was unsubstantiated.

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.

The facility was found deficient in multiple areas including failure to maintain a homelike environment due to damaged walls and stained floors, inadequate grievance resolution, incomplete baseline care plans for new admissions, failure to involve residents or representatives in care conferences, inadequate personal hygiene care, improper use of bed rails without assessment or consent, lapses in infection control practices, and an ongoing pest control problem with mice in resident rooms.

Complaints #107934-C and #108039-C were substantiated. Facility reported incidents #108701-1 and #108702-1 were substantiated.

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.

Investigation of complaints #98537-C, #99584-C, #100925-C, and #100913-C was conducted and substantiated during the survey.

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.

Complaint #97951 and #98137 were investigated and found not substantiated.

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.

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.

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.

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.

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.

Complaint #91529-C was substantiated. The investigation revealed failures in infection prevention and control related to COVID-19.

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.