University City Rehabilitation and Healthcare CTR

In the surveyor’s words

From the most serious findings on record at University City Rehabilitation and Healthcare CTR, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jul 7, 2021

  Based on observations, review of facility policies, facility documentation and interviews with staff, it was determined that the facility failed to ensure that water temperatures in resident bathroom hand sinks were maintained at a safe temperature for two of two nursing units observed (First Floor and Second Floor Nursing Units). This failure placed residents on the First and Second Floor Nursing Units at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation for 52 of 109 residents (Resident R4, R5, R7, R8, R10, R12, R13, R14, R15, R16, R18, R29, R30, R33, R37, R40, R44, R45, R46, R48, R49, R51, R52, R62, R64, R72, R73, R74, R79, R83, R85, R88, R89, R90, R91, R92, R93, R104, R105, R107, R110, R112, R114, R116, R118, R121, R124, R128, R230, R300, R301, and… […]

• Actual harm, isolatedF689Apr 24, 2023

  Based on review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to ensure that Resident R1 was properly secured during transfer via the use of a sit-to-stand mechanical device and failed to ensure that the safest mechanical device was utilized during transfer for one of four residents reviewed (Resident R1). This failure resulted in actual harm to Resident R1 who sustained a fracture of the right tibia and fibula. Findings include: Review of undated facility policy Lifting Machine, Using a Mechanical revealed the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. Mechanical lifts may be used for tasks such as transferring a resident from bed to chair. […]

• Actual harm, isolatedF697Jul 7, 2021

  Based on review of clinical records, resident interview, and staff interviews, it was determined that the facility failed to make certain that proper pain management was provided for one of 10 residents reviewed (Resident R67), resulting in harm when the resident suffered severe pain without effective relief. Findings include: A clinical record review revealed that Resident R67 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual Minimum Data Set assessment (MDS - a comprehensive, standardized assessment of each resident's functional capabilities and health needs) dated 5/7/21, indicated that the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF756Jul 7, 2021

  Based on clinical record review and staff interviews, it was determined the facility failed to make certain that the monthly Medication Regimen Reviews (MRR) were conducted for one of two residents (Resident R27). Findings include: The review of the State Operations Manual 483.45(c)(1) indicated that drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. A clinical record review revealed that Resident R27 was admitted to the facility on [DATE], with diagnoses that included [CONDITION(S)], muscle weakness, pressure ulcers, [CONDITION(S)], and anxiety. […]

• No harm, potential for more than minimal, widespreadF761Jul 7, 2021

  Based on accepted standards of practice, manufacturer guidelines, observation and staff interview, it was determined that the facility failed to date opened insulin pens (single resident pen type device for injecting insulin) in two of two medication carts (1st floor back hall and 2nd floor back hall medication carts), and to properly secure medications in the medication cart (2nd floor back hall). Findings include: The United States Pharmacopeia (USP) General Chapter 797 recommends that if a multi-dose has been opened or accessed, the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. […]