Inspection Reports for University Place Nursing & Rehabilitation
9200 Glenwater Dr, Charlotte, NC 28262, NC, 28262
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
14.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
183% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Deficiencies: 2
Date: Jul 24, 2025
Visit Reason
The inspection was conducted to assess compliance with food procurement, storage, preparation, distribution, and serving standards in the facility kitchen.
Findings
The facility failed to remove a dented can and failed to reseal, label, and date leftover food items stored for use in the walk-in freezer and dry storage room, potentially affecting food safety for residents.
Deficiencies (2)
Failed to remove a dented can located on shelf ready for use.
Failed to reseal and label and date leftover food items stored for use in the walk-in freezer and dry storage room.
Report Facts
Weight of Texas Toast bread: 15.33
Weight of churros: 7.93
Weight of cheese omelets: 18.9
Weight of cookie dough balls: 20
Weight of brown gravy mix: 22.6
Weight of white sugar: 31
Weight of elbow macaroni: 160
Weight of complete mashed potatoes: 57
Weight of can of pears: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding food storage practices and deficiencies | |
| Administrator | Interviewed regarding expectations for kitchen staff compliance |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jul 24, 2025
Visit Reason
The inspection was conducted following a complaint regarding a resident-to-resident altercation where Resident #23 hit Resident #96 in the face, resulting in injury. The investigation focused on the facility's failure to protect residents from abuse.
Complaint Details
The complaint investigation was triggered by an incident on 7/16/2025 where Resident #23 hit Resident #96 in the face. The facility conducted an investigation, placed both residents on one-to-one supervision, moved Resident #23 to another room, and notified appropriate authorities. The abuse was not substantiated as willful harm.
Findings
The facility failed to protect a resident from abuse when Resident #23 struck Resident #96, causing a minor injury. The incident was investigated, and both residents were placed on one-to-one supervision, with Resident #23 moved to another room. The abuse was not substantiated as willful harm. Additional deficiencies were found related to expired medications, improper food storage, inaccurate wound care documentation, and failure to follow infection control policies.
Deficiencies (5)
Failed to protect residents from abuse when Resident #23 hit Resident #96 in the face causing a slight swelling.
Failed to remove expired medications from medication cart.
Failed to properly store and label food items, including a dented can and unlabeled leftovers.
Failed to maintain accurate wound care documentation for Resident #110, not documenting changes in wound treatment orders.
Failed to implement infection control policies: Nurse #3 did not perform hand hygiene properly during medication administration; NA #3 and NA #4 failed to wear PPE during high contact care activities.
Report Facts
Date of incident: Jul 16, 2025
Medication expiration dates: 2
Wound care order date: May 1, 2025
Wound care consultation date: Jun 25, 2025
Compliance date: Jul 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | First staff to respond to resident altercation on 7/16/2025 | |
| Nursing Aide #1 | Provided one-to-one supervision for Resident #23 after altercation | |
| Social Worker #1 | Provided emotional support and one-to-one supervision to Resident #96 after incident | |
| Assistant Director of Nursing | ADON | Documented nursing note on altercation and interviewed regarding incident |
| Nurse Practitioner | Assessed residents after altercation and ordered labs, x-rays, and referrals | |
| Director of Nursing | DON | Interviewed regarding medication cart and infection control deficiencies |
| Administrator | Conducted investigation and provided plan of correction | |
| Nurse #3 | Observed failing hand hygiene during medication administration | |
| Nursing Aide #3 | Observed failing to wear PPE during high contact care | |
| Nursing Aide #4 | Observed failing to wear PPE during high contact care | |
| Wound Nurse #1 | Weekend wound nurse involved in wound care documentation issue | |
| Wound Nurse #2 | Weekday wound nurse involved in wound care documentation issue | |
| Medical Director | Approved wound care treatment orders and interviewed about documentation | |
| Dietary Manager | DM | Interviewed regarding food storage deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 15, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a significant medication error involving Resident #1, who did not receive a prescribed seizure medication (Cenobamate) from 9/05/24 through 9/18/24, resulting in a mild seizure.
Complaint Details
The complaint investigation revealed Resident #1 experienced a mild seizure on 9/18/24 due to not receiving Cenobamate from 9/05/24 through 9/18/24. The medication was not on the medication cart, but nurses documented it as given. The facility initiated an investigation, notified the physician and family, and implemented corrective actions including staff education and audits.
Findings
The facility failed to ensure Resident #1 was free from significant medication errors when 14 doses of Cenobamate were not administered as ordered. Nurses documented administering the medication though it was not available on the medication cart. The error was linked to failure to follow the 6 rights of medication administration and lack of communication with the pharmacy. Corrective actions including audits, staff education, and monitoring were implemented.
Deficiencies (2)
Failure to administer 14 doses of Cenobamate seizure medication to Resident #1 as ordered from 9/05/24 through 9/18/24.
Failure to accurately document medication administration for 14 doses of Cenobamate in Resident #1's medical record.
Report Facts
Doses of medication not administered: 14
Medication doses documented as given: 14
Therapeutic drug levels: 90
Therapeutic drug levels: 13.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Notified ADON of missing Cenobamate on medication cart and involved in investigation | |
| Nurse #2 | 2nd shift nurse assigned to Resident #1, unaware medication was missing, documented administration | |
| Nurse #3 | 2nd shift nurse assigned to Resident #1, unaware medication was missing, documented administration | |
| Nurse #4 | Signed nurse's note documenting seizure event on 9/18/24 | |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Notified Administrator, initiated investigation, and oversaw corrective actions |
| Physician Assistant (PA) | Physician Assistant | Evaluated Resident #1 post-seizure and commented on significance of medication error |
| Pharmacist | Confirmed medication orders and dispensing history, noted missing medication requests | |
| Administrator | Administrator | Notified of medication error, led investigation and corrective action plan |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 27, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding medication administration errors and food service issues at University Place Nursing and Rehabilitation Center.
Complaint Details
The complaint involved medication administration errors where a plastic bag used for crushing medications was not properly disposed of and ended up on a resident's breakfast tray. The resident mistakenly sprinkled the contents on his food. The complaint also included concerns about food service not meeting dietary orders and resident preferences.
Findings
The facility failed to properly dispose of medication packaging, resulting in a plastic bag with crushed medication ending up on a resident's breakfast tray. Additionally, the facility failed to provide food in the appropriate form for a resident with a mechanical soft diet order and did not accommodate a resident's food preferences for scrambled eggs.
Deficiencies (3)
Failed to dispose of a plastic bag used to crush medications, which ended up on another resident's breakfast tray.
Failed to provide food in a form to meet the individual needs of a resident with a mechanical soft diet order; bacon was served in large pieces instead of ground.
Failed to provide food that accommodated a resident's preference for scrambled eggs; resident received cheese omelet instead.
Report Facts
Residents reviewed for medication errors: 5
Medication pass observation opportunities: 30
Completion date for corrective action plan: 2024
Frequency of bacon served: 3
Frequency of bacon served: 2
Resident #19 observation date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Named in medication packaging disposal incident and interviews regarding the event | |
| Nurse Aide #1 | Interviewed regarding medication packaging incident and food service for Resident #19 | |
| Unit Manager #1 | Interviewed regarding medication packaging incident and food service observations | |
| Director of Nursing | DON | Interviewed regarding medication packaging incident and corrective actions |
| Physician Assistant | Interviewed regarding medication dosage and potential effects | |
| Former Social Worker | SW | Interviewed regarding medication packaging incident and resident interviews |
| Speech Therapist | ST | Interviewed regarding Resident #19's diet order and swallowing risks |
| Certified Foodservice Manager | CFM | Interviewed regarding food service and tray card preferences for Resident #19 |
| Registered Dietitian | RD | Interviewed regarding Resident #19's diet and food preferences |
| Rehab Director | Interviewed regarding Resident #19's swallowing evaluation and diet order | |
| Administrator | Interviewed regarding Resident #19's food preferences and food committee meetings | |
| Nurse Consultant | Interviewed regarding education documentation for Resident #19 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 9, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to safely assist a resident without causing injury during transfers.
Complaint Details
The complaint investigation found that Resident #1 was transferred by an agency Nurse Aide alone without mechanical lift or assistance, contrary to the care plan. The Nurse Aide was unaware of the resident's history of falls and care requirements. Interviews with Unit Manager, Nurse, Director of Nursing, and Administrator confirmed the resident required two-person mechanical lift transfers and that staff had been educated accordingly.
Findings
The facility failed to follow the care plan for Resident #1, who required a mechanical lift and two-person assistance for transfers. An agency Nurse Aide transferred the resident alone without the required lift or posted care guide, despite staff education on following care plans.
Deficiencies (1)
Failure to ensure safe assistance during resident transfers, specifically transferring Resident #1 alone without mechanical lift or proper assistance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #1 | Agency Staff Nurse Aide | Transferred Resident #1 alone without mechanical lift or assistance, unaware of care plan. |
| Unit Manager #1 | Unit Manager | Interviewed regarding Resident #1's transfer status and staff education. |
| Nurse #1 | Nurse | Interviewed confirming Resident #1 required mechanical lift and staff education. |
| Director of Nursing | Director of Nursing (DON) | Interviewed confirming staff education and care plan requirements for Resident #1. |
| Administrator | Administrator | Interviewed confirming staff education and transfer requirements for Resident #1. |
Inspection Report
Routine
Deficiencies: 2
Date: May 30, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding residents' ability to self-administer medications and the provision of care for activities of daily living, specifically nail care, for dependent residents.
Findings
The facility failed to assess residents for the ability to self-administer medications for 2 of 2 residents reviewed and failed to provide adequate nail care for 2 of 3 dependent residents reviewed. Observations, record reviews, and interviews revealed medications were left at residents' bedsides without proper assessment and nail care was not consistently performed or documented.
Deficiencies (2)
Failure to assess residents for the ability to self-administer medications, resulting in medications being left at residents' bedsides without authorization or care plans.
Failure to provide nail care for dependent residents, resulting in long, dirty fingernails with brown substance underneath.
Report Facts
Residents affected: 2
Residents affected: 2
Medication administration times: 2
Fingernail length: 0.25
Fingernail length: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Nurse | Administered medications to Resident #2 and involved in medication observation |
| Nurse #2 | Nurse | Interviewed regarding medication self-administration and medication left at Resident #3's bedside |
| Director of Nursing | Director of Nursing | Interviewed regarding facility policy on medication self-administration and nail care |
| Administrator | Administrator | Interviewed regarding medication self-administration policy and nail care practices |
| NA #1 | Nurse Aide | Assigned to shower team, reported on nail care practices and shower duties |
| NA #2 | Nurse Aide | Assigned to shower team, reported on nail care responsibilities |
| NA #3 | Nurse Aide | Reported observations of Resident #4's fingernails |
| NA #4 | Nurse Aide | Provided shower to Resident #4 and reported on nail care |
| Staff Development Coordinator | Staff Development Coordinator | Reported on staff training regarding nail care |
| Unit Manager | Unit Manager | Reported on staff education and nail care monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Mar 13, 2024
Visit Reason
The inspection was conducted based on complaints and observations regarding failure to provide resident preferences for showers, failure to revise care plans, medication errors, insufficient nursing staff, and infection control issues.
Complaint Details
The complaint investigation revealed multiple deficiencies including failure to provide scheduled showers, medication errors due to insufficient staffing and poor supervision, failure to revise care plans, and infection control breaches.
Findings
The facility failed to provide scheduled showers and hair washing to residents, failed to revise care plans timely, failed to administer medications as ordered resulting in significant medication errors, failed to provide sufficient nursing staff, failed to supervise a nurse in training leading to medication errors, and failed to follow infection control hand hygiene policies during wound and incontinence care.
Deficiencies (10)
Failed to provide resident #49 scheduled showers twice weekly as preferred.
Failed to revise smoking care plan for Resident #75, resolve inactive care plans for Resident #51, and schedule quarterly care plan meetings for Resident #83.
Failed to follow physician orders for wound care and medication administration for multiple residents including Resident #128, #28, and #110.
Failed to provide showers and hair washing to Resident #94 and failed to provide proper incontinence care to Resident #51.
Failed to plan group activities outside the facility for residents who expressed importance of such activities (Residents #17, 31, 35, and 110).
Failed to complete quarterly smoking assessment for Resident #75.
Failed to provide sufficient nursing staff to meet resident needs and ensure medication administration and assistance with activities of daily living.
Failed to provide effective orientation and supervision to a new nurse resulting in medication errors for Resident #83.
Failed to prevent significant medication errors for 9 residents including Resident #7, #28, #47, #51, #73, #79, #88, #110, and #83.
Failed to ensure staff implemented hand hygiene and glove use policies during wound care and incontinence care for Residents #128, #43, #126, and #51.
Report Facts
Residents affected by medication errors: 9
Residents reviewed for medication errors: 16
Residents reviewed for ADL assistance: 10
Residents reviewed for wound care: 3
Residents reviewed for incontinence care: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #8 | Nurse | Failed to supervise Nurse #9 during medication administration resulting in medication errors. |
| Nurse #9 | Nurse in training | Administered wrong medications to Resident #83. |
| Nurse #1 | Nurse | Reported Nurse #2 called out and was involved in medication administration on 12/10/2023 shift. |
| Nurse #2 | Nurse | Called out for 7:00 PM to 11:00 PM shift on 12/10/2023 causing medication errors. |
| Nurse #3 | Nurse | Instructed to split medication cart on 12/10/2023 shift. |
| Nurse #4 | Nurse | Instructed to split medication cart on 12/10/2023 shift. |
| Nurse #5 | Nurse | Administered half of medications on 12/10/2023 shift; communication error led to missed medications. |
| NA #1 | Nurse Aide | Observed providing incontinence care with improper glove use and hand hygiene. |
| NA #4 | Nurse Aide | Interviewed about shower schedule issues for Resident #49. |
| Unit Manager #1 | Unit Manager | Interviewed about shower scheduling and staffing issues. |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding medication errors, shower scheduling, and infection control. |
| Infection Preventionist | Infection Preventionist | Interviewed regarding hand hygiene education for Treatment Nurse. |
| Treatment Nurse | Nurse | Observed failing to follow hand hygiene and glove protocols during wound care. |
| Activity Director | Activity Director | Interviewed about lack of group activities outside the facility due to transportation issues. |
| Administrator | Administrator | Interviewed about transportation issues and group activities outside the facility. |
Inspection Report
Complaint Investigation
Deficiencies: 13
Date: Feb 27, 2024
Visit Reason
The inspection was conducted based on complaints and concerns regarding failure to provide scheduled showers, inaccurate assessments, medication errors, and infection control issues.
Complaint Details
The complaint investigation revealed multiple issues including failure to provide scheduled showers, inaccurate assessments, medication errors, infection control breaches, and inadequate staffing.
Findings
The facility failed to provide scheduled showers and hair washing to some residents, failed to accurately code assessments, failed to complete required PASRR screenings, failed to administer medications as ordered resulting in significant medication errors, failed to follow infection control procedures including hand hygiene, and failed to maintain adequate staffing levels to meet resident needs. Additionally, the facility did not ensure group activities outside the facility and had issues with food storage and quality assurance monitoring.
Deficiencies (13)
Failed to provide scheduled showers and hair washing to Resident #49 and Resident #94 as preferred and documented.
Failed to accurately code Minimum Data Set (MDS) assessments for PASRR and restraints for multiple residents.
Failed to complete required PASRR level II screenings for residents with mental health diagnoses.
Failed to revise care plans timely and schedule quarterly care plan meetings for some residents.
Failed to follow physician orders for wound care treatments for Resident #128 and failed to administer medications as ordered for multiple residents.
Failed to provide showers and hair washing and failed to provide incontinence care as trained for some residents.
Failed to plan group activities outside the facility for residents who expressed the importance of such activities.
Failed to provide sufficient nursing staff to ensure medications were administered as ordered and assistance with activities of daily living.
Failed to provide effective orientation and supervision to a new nurse resulting in a resident receiving wrong medications.
Failed to label insulin pens with open dates, failed to discard expired insulin pens, and failed to store unopened insulin pens in the refrigerator.
Failed to remove expired food items and unlabeled staff items from nourishment rooms.
Failed to ensure staff implemented hand hygiene and glove use policies during wound care and incontinence care.
Failed to maintain effective Quality Assessment and Assurance (QAA) program to sustain compliance with previously identified deficiencies.
Report Facts
Residents affected by shower scheduling deficiency: 2
Residents reviewed for PASRR coding: 6
Residents reviewed for medication errors: 16
Residents reviewed for wound care: 3
Residents reviewed for incontinence care: 3
Insulin pen expiration days: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #8 | Nurse | Failed to supervise nurse in training during medication administration resulting in medication error |
| Nurse #9 | Nurse in training | Administered wrong medications to Resident #83 |
| Director of Nursing | Director of Nursing | Provided interviews regarding multiple deficiencies and expectations |
| Unit Manager #1 | Unit Manager | Provided interviews regarding shower scheduling and staffing issues |
| MDS Coordinator #1 | MDS Coordinator | Provided interviews regarding inaccurate MDS coding and care plan issues |
| MDS Coordinator #2 | MDS Coordinator | Provided interviews regarding inaccurate MDS coding and care plan issues |
| Nurse Aide #1 | Nurse Aide | Observed providing incontinence care with infection control breaches |
| Nurse Aide #4 | Nurse Aide | Interviewed about shower scheduling for Resident #49 |
| Nurse Aide #7 | Nurse Aide | Interviewed about shower scheduling for Resident #94 |
| Nurse Aide #8 | Nurse Aide | Interviewed about shower scheduling for Resident #94 |
| Nurse Aide #12 | Nurse Aide | Interviewed about shower scheduling for Resident #94 |
| Social Worker #2 | Social Worker | Interviewed about overdue care plan meetings |
| Activity Director | Activity Director | Interviewed about lack of group activities outside the facility |
| Medical Director | Medical Director | Interviewed about medication errors and resident monitoring |
| Infection Preventionist | Infection Preventionist | Interviewed about hand hygiene education and monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Aug 25, 2022
Visit Reason
The inspection was conducted based on complaints and observations related to resident care, safety, sanitation, and assessment accuracy at University Place Nursing and Rehabilitation Center.
Complaint Details
The visit was complaint-related, triggered by allegations concerning resident care, sanitation, food safety, and assessment accuracy. Specific substantiation status is not stated.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs (broken light fixture cord), unsanitary bathroom conditions, inaccurate coding of tobacco use in resident assessments, failure to discard expired and spoiled food items, improper garbage disposal and grease trap maintenance, and ineffective Quality Assessment and Assurance (QAA) program oversight.
Deficiencies (6)
Failed to provide access to control the light fixture behind the bed for 1 resident (Resident #96).
Failed to keep a sanitary environment in a shared bathroom for 2 residents (Residents #35 and #70).
Failed to accurately code the Minimum Data Set (MDS) related to tobacco use for 3 residents (Residents #3, #138, and #139).
Failed to discard produce with signs of spoilage, remove expired food items and date leftover food stored ready for use in the walk-in cooler.
Failed to ensure garbage was contained in a closed dumpster and maintain a clean grease trap free of buildup.
Failed to maintain implemented procedures and monitor interventions in the Quality Assessment and Assurance (QAA) program.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 3
Expired cantaloupes: 10
Prune juice containers: 35
Date of last grease pick up: Mar 21, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Manager | Acknowledged missing broken light fixture cord during daily walk through and responsible for grease trap maintenance | |
| Nurse #2 | Did not notice broken light fixture cord | |
| Nurse Aide (NA) #2 | Did not notice broken light fixture cord | |
| Unit Manager | Expected nursing staff to report repair needs timely and attributed MDS coding errors to oversight | |
| Administrator | Expected timely reporting of repair needs, accurate MDS coding, and proper food safety and sanitation practices | |
| Housekeeping Aide | Did not clean inside of trash can and did not inform maintenance or supervisor about soiled trash can | |
| Housekeeping Supervisor | Responsible for ensuring trash cans are cleaned and acknowledged housekeeping staffing shortages | |
| Dietary Supervisor | Responsible for discarding expired foods and inventory of refrigerated foods | |
| Corporate Dietician | Confirmed Dietary Supervisor's responsibility for inventory of refrigerated foods | |
| Travelling MDS Coordinator | Acknowledged MDS coding errors and planned to correct and resubmit affected MDS | |
| Nurse Aide (NA) #1 | Supervised smokers in courtyard and confirmed residents smoked regularly |
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