University Care Center

In the surveyor’s words

From the most serious findings on record at University Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812May 7, 2025

  Based on observation , interview and record review, the facility failed to ensure clean and used utensils were separated during a preparation of pureed meals. This failure had the potential to affect the health and safety of all residents. An observation on 5/5/25 at 10:30 A.M., was conducted with the [NAME] (CK) and the registered dietician (RD). The CK was observed preparing a pureed meal for 9 residents in the facility. The CK placed 20 pieces of tortillas and 3 cups of turkey meat in a chicken broth and placed them in a blender. The CK used a large mixing spoon to mix the tortillas and the turkey meat in the blender. The CK stated she wanted to make sure that the mixture was smooth and was free of lumps after blending the ingredients together. […]

• No harm, potential for more than minimal, patternF842May 7, 2025

  Based on interview and record review, the facility failed to maintain complete Physician Orders for Life Sustaining Treatment (POLST - a medical form to communicate a resident's end of life wishes) for three of 18 residents (4,128, 129) reviewed for complete and accurate medical records. This failure did not provide an accurate representation of the care provided and had the potential to cause confusion amongst care providers. Findings: 1. Resident 4 was re-admitted on [DATE] to the facility with diagnoses to include dementia (type of memory loss), muscle weakness and adult failure to thrive according to the Admisison Record. 2. […]

• No harm, potential for more than minimal, patternF880May 7, 2025

  Based on observation, interview and record review, the facility did not ensure infection control practices were implemented when: 1. Clean linens were mixed with packages that were transported from outside facility 2. Trash cans were inside the clean linen closets 3. Dusty and debris on the floor of the clean linen closets 4. A licensed nurse (LN 21) did not wear an isolation gown while administering medications to a resident (1) with a gastrostomy tube (GT-feeding tube inserted through the belly to bring nutrition and medications directly to the stomach). These failures had the potential to spread infections. Findings: 1. On 5/7/25 at 8:28 A.M., a concurrent observation and interview were conducted with the Director of Environmental Services (DES) and Infection Preventionist Nurse (IP). […]

• No harm, potential for more than minimal, patternF656Feb 17, 2023

  Based on observation, interview, and record review, the facility failed to ensure written care plans were developed and/or implemented for four of 19 residents (246, 20, 41, 14) when: 1. Resident 246 did not have a written care plan developed related to pain. 2. Resident 20 did not have a written care plan developed related to oxygen therapy. 3. The Activities care plan of Resident 41 was not implemented. 4. Resident 14 did not have a written care plan developed related to dentures. As a result of this deficient practice, there was the potential for residents to not receive individualized care that met their needs. Findings: 1. […]

• No harm, potential for more than minimal, patternF755Feb 17, 2023

  Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmacy services to meet the needs of the residents by failing to: 1. Remove a discontinued medication from the medication cart for a discharged resident in a timely manner; 2. Label with the time and date of activation (contact between previously separated diluent and medication) of the Mini Bag Plus - piperacillin/tazobactam (antibiotic for injection into vein) vial system before storage in the medication refrigerator; 3. Clarify a physician order to provide pain medication only for moderate pain for one of five residents reviewed (Resident 8); and 4. Correctly administer a pain medication based on the perceived level of pain for one of five residents reviewed (Resident 33). 5. […]