University Heights Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jul 19, 2023

  Based on interviews and record review, the facility failed to protect and keep safe from abuse and neglect two (#1 and #3) residents out of six sample residents. On 6/12/23 the facility failed to send an escort to a medical appointment outside of the facility with Resident #1 who had cognitive impairment, Parkinson's Disease and autism. The facility had evaluated Resident #1 was unsafe to go out of the building by herself three different times (11/7/22, 1/22/23, and 4/18/23) prior to the appointment on 6/12/23. Resident #1 was dropped off at a medical office building by herself, and was found wandering down a hallway not in the physician's waiting area by the medical office personnel. The medical personnel called the facility to come and help Resident #1. […]

• Actual harm, isolatedF686Sep 29, 2022

  Based on observations, interviews, and record review, the facility failed to ensure the necessary care and treatment to prevent the development of pressure injuries for one (#74) of two residents reviewed of 39 sample residents. Resident #74 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted with hospice care and was followed by the wound physician. The resident was admitted with one stage 4 pressure ulcer to her sacrum. On 3/29/22 the resident developed a stage 2 pressure ulcer to her right lateral knee. On 4/19/22 the right lateral knee wound had developed to a stage 4 and a stage 2 pressure ulcer to the right scapula had developed. On 5/17/22 the right scapula wound had developed to a stage 4. […]

• Actual harm, isolatedF692Sep 29, 2022

  Based on record review and interviews, the facility failed to ensure one (#74) of three out of 39 sample residents received the care and services necessary to meet their nutritional needs and to maintain their highest level of physical well being. Resident #74 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted with one stage 4 pressure ulcer to her sacrum and later developed three additional pressure ulcers. Dietary interventions included Mighty Shakes and Ensure Plus (nutritional supplements) with no additional interventions trialed as the resident's wounds continued to deteriorate (cross-reference F686 for pressure injuries). In August 2022, a 34.2 pound weight loss was noted with a reweight requested to verify weight loss. […]

• Actual harm, isolatedF600Jun 22, 2021

  Based on observations, record review and interviews the facility failed to ensure that residents were free from abuse, for three (#124, #15 and #2) out of five residents reviewed for incidents of abuse out of 38 sample residents. The facility failed to ensure Resident #124 had the right to be free from abuse, when a staff member of the facility took an unauthorized video/recording of the resident on a personal cell phone after the resident had fallen out of bed and was in a state of undress; and shared the eight minute video with other facility staff over social media. The video of Resident #124 was taken during a time when personal care for the resident was needed after the resident fell out of bed. […]

• Actual harm, isolatedF760Jun 22, 2021

  Based on record review and interview, the facility failed to ensure one (#72) of two residents out of 38 sample residents did not experience a significant medication error. Specifically, the facility failed to ensure Resident #72's intravenous (IV) medication was administered as ordered; that [MEDICATION(S)] lab trough levels were obtained as ordered prior to medication administered as ordered by the physician; and sufficient medication was on hand to administer. Resident #72 was on IV [MEDICATION(S)] antibiotic medications to treat a severe infection in his legs and feet. The infectious disease physician ordered regular lab testing of the [MEDICATION(S)] medication levels in the resident's blood. The labs were to be sent to the physician and the pharmacy. […]