University Heights Health and Living Community

In the surveyor’s words

From the most serious findings on record at University Heights Health and Living Community, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF755Nov 7, 2024

  Based on observation, interview, and record review, the facility failed to ensure controlled medications were reconciled accurately for 4 of 8 medication carts. (200 Hall Medication Cart, 100 Hall Medication Cart, 400 Hall Medication Cart, 700/800 Hall Medication Cart) Findings include: 1. On 11/7/24 at 12:44 p.m., during the controlled medication reconciliation for the 200 hall medication cart, the Nurse's Narcotic Sign In/Out Sheet, dated 11/1/24 until 11/7/24 at 12:44 p.m., was reviewed. The document had a grid with lines that were numbered to correspond with each day of the month. […]

• No harm, potential for more than minimal, patternF554Aug 27, 2024

  Based on observation, interview, and record review, the facility failed to ensure self-medication administration assessments were completed for 4 of 4 residents observed with medications at bedside. (Resident 53, Resident 1, Resident 105, Resident 39) Findings Include: 1. On 8/20/24 at 10:32 a.m., observed Resident 53 was sitting up in bed; no staff were observed to be in the room or in hallway. Resident 53 had an overbed table with the following observed to be sitting on top of the table; one clear plastic medication cup containing two small white tablets and one and a half large tablets. On 8/21/24 at 8:33 a.m., Resident 53 was observed sitting up in bed eating. […]

• No harm, potential for more than minimal, isolatedF689Aug 25, 2026

  Based on interview and record review, the facility failed to prevent a cognitively impaired resident residing on a locked memory care unit from exiting from the facility for 1 of 1 resident reviewed for elopement. (Resident E) The deficient practice was corrected on August 14, 2026, prior to the start of the survey, and was therefore past noncompliance. Finding includes: On 8/24/26 at 12:40 p.m., Resident E's clinical record was reviewed. Resident E's diagnoses included, but were not limited to, vascular dementia and Alzheimer's disease. Resident E admitted to the facility for placement on their locked memory care unit. […]

• No harm, potential for more than minimal, isolatedF760Aug 25, 2026

  Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents reviewed. A controlled substance medication was given routinely instead of as needed. (Resident C) This deficient practice was corrected on August 11, 2026, prior to the start of the survey, and was therefore past noncompliance. Finding includes: On 8/24/26 at 11:25 a.m., Resident C's clinical record was reviewed. Resident C's diagnoses included, but were not limited to, dementia, congestive heart failure (a chronic condition where the heart muscle cannot pump blood efficiently), and cerebrovascular disease (a term for any condition that temporarily or permanently reduces blood flow or damages blood vessels in the brain). […]

• No harm, potential for more than minimal, isolatedF658May 12, 2026

  Based on observation, interview, and record review, the facility failed to ensure follow-up for physician orders and instructions for care were obtained for a new positioning device (splint) following an off-site medical appointment for 1 of 1 resident reviewed for splints. (Resident 98) Findings includes: On 5/6/26 at 1:20 p.m., Resident 98 was observed sitting in a rocking chair in the activity room. Resident 98 was observed wearing a black positioning device (splint) on her left wrist. During an interview at that time, Resident 98 indicated she had worn the splint for a month or so. On 5/6/26 at 1:02 p.m., Resident 98's clinical record was reviewed. The diagnosis included, but was not limited to, a fractured carpal bone (small bone located in the left wrist). […]