University Center for Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at University Center for Rehabilitation and Nursing, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF803May 7, 2024

  Based on observation, record review, and interviews conducted during the Recertification survey from 5/1/2024 to 5/7/2024, the facility did not ensure that resident menus were followed, and food preferences were honored. This was evident for 4 (Residents #38, # 95, and # 4) of 12 total sampled residents. Specifically, 1) Residents #38, #95, and #4 did not receive food items listed on their lunch and dinner meal ticket, and 2) Resident #38 did not receive preferred food items as requested. The findings are: The facility policy titled Tray Assembly Identification and Service Policy that was last reviewed in January 2024 documented tickets are used to identify correct items for resident diet and are placed at resident place setting or on tray. […]

• No harm, potential for more than minimal, patternF812May 7, 2024

  Based on observation, record review, and interview, during the Recertification Survey from [DATE] to [DATE], the facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards for food service safety. This was evident during the kitchen observation. Specifically, 1.) multiple food items were observed in the refrigerators without proper labeling, 2.) opened food items were not dated, 3.) expired food items were observed, and 4.) food was not stored away from rust or soiled surfaces. The findings are: A facility policy and procedure titled Food Storage which was last revised on [DATE] stated that food will be stored in an area that is clean, dry and free from contaminants. All stock must be rotated with each new order received. […]

• No harm, potential for more than minimal, isolatedF641Mar 25, 2026

  Based on observations, record reviews, and interviews, the facility did not ensure that assessments accurately reflected the residents' status. This was evident for one (1) of one (1) resident (Resident #3) reviewed for Respiratory Care out of forty-six (46) sampled residents. Specifically, The Minimum Data Set 3.0 (MDS) assessment did not document Resident #3 was in use of continuous oxygen. The findings are: Resident #3 had diagnoses upon admission that included Non-Alzheimer's Dementia, Deep venous thrombosis (DVT), and bipolar disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented that the resident's cognitive status was severely impaired. The Minimum Data Set assessment did not document that the resident was use of continuous oxygen at the time of assessment. […]

• No harm, potential for more than minimal, isolatedF695Mar 25, 2026

  Based on observation, record review and interview, the facility did not ensure that residents received necessary respiratory care consistent with professional standards of practice and the comprehensive care plan. This was evident for one (1) of one (1) resident (Resident #3) reviewed for Respiratory Care out of forty-six (46) sampled residents. Specifically, Resident #3 was observed receiving oxygen via nasal cannula at a rate of four (4) liters per minute when the Physician's Order was written for oxygen to be received at a rate of two (2) liters per minute. […]

• No harm, potential for more than minimal, isolatedF842Mar 25, 2026

  Based on observation, record review, and staff interviews, the facility did not ensure that the resident medical records were accurately documented in accordance with professional standards of practice. This was evident for one (1) of three (3) residents (Resident #50) reviewed for Closed Records out of forty-six (46) total sampled residents. Specifically, Resident #50 was discharged to the hospital on [DATE], but the resident's medical record revealed that the resident was seen on 03/12/2026 and 03/19/2026 by behavioral health staff despite not having returned to the facility. The findings are: Resident #50 was admitted to the facility with diagnoses that included non-Alzheimer's dementia, depression, heart failure, and diabetes mellitus. […]