University Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF580Nov 5, 2024

  Based on record reviews, and staff, Nurse Practitioner (NP), responsible party, and Resident interviews, the facility failed to notify the physician and responsible party of changes in condition for of 1 of 1 resident (Resident #7). Resident #7 had intact cognition and a history of stroke and on 10/21/24 at approximately 9:00 PM he reported to a nurse aide (NA) he had pain and numbness in his left arm and leg. The NA aide reported this to the nurse. On the next shift at approximately 6:00 AM Resident #7 informed another NA he could not feel his left side. The NA reported this to the nurse. […]

• Immediate jeopardy, isolatedF684Nov 5, 2024

  Based on observation, record review, resident, family member, staff, Emergency Medical Technician (EMT), Physician, and Nurse Practitioner (NP) interviews, the facility failed to comprehensively assess a resident (Resident #1) who had untreated obstructive sleep apnea (a condition that causes the upper airway to become blocked during sleep, reducing or stopping airflow) to determine the root cause of periodic abdominal pain, change in mental status, and migraines that occurred intermittently over the last 6 months in conjunction with Carbon Dioxide (CO2) levels near the upper limit of the reference range (a set of numbers that are the high and low ends of the range of results that's considered to be normal) in August 2024 and October 2024. […]

• Immediate jeopardy, isolatedF600Jan 14, 2022

  Based on record review, staff, Nurse Practitioner (NP) and facility and hospital Physician's interviews, the facility neglected to monitor, assess and identify a resident's skin that was irritated and bleeding behind the ears from a surgical face mask strap that resulted in a partial thickness injury of one ear and a full thickness injury and partial amputation of the other ear for 1 of 2 sampled residents reviewed for injury (Resident #1). Immediate Jeopardy began on 12/10/21 when the NP and staff observed surgical face mask elastic over the resident's ears with debris present, hair stuck, scabbing and redness. This observation was followed by inaccurate assessments, continued use of the same mask, poor hygiene and poor communication about the area. […]

• Actual harm, isolatedF689May 9, 2024

  Based on record review and staff and physician interviews the facility failed to safely transfer a resident when utilizing a sit to stand lift for 1 of 3 residents reviewed for accidents (Resident #1). This unsafe transfer resulted in Resident #1 sustaining a mildly displaced left medial malleolus (boney presence on the inner side of the ankle) fracture and pain of 5 on a scale of 1 to 10 (10 being the worst pain). Finding included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, contractures to right hand, contractures to right knee and contractures to left knee. […]

• Actual harm, isolatedF600Mar 6, 2024

  Based on record review, resident, staff, Physician, Psychiatric Nurse Practitioner, and Administrator interviews the facility failed to protect a resident's right to be free from employee to resident physical abuse, when an employee (receptionist) threw a plexiglass (acrylic) mask holder hitting Resident #2 on his forehead. The resident had a fall, and a laceration on his forehead. The resident was angry and upset when he was hit by the object thrown by the staff member. Resident #2 was sent to the emergency room and had undergone a procedure for 5 sutures on his forehead. This was for 1 of 2 residents reviewed for abuse (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE]. […]