University Manor Health & Reha

In the surveyor’s words

From the most serious findings on record at University Manor Health & Reha, in the surveyor’s own words.

• Immediate jeopardy, patternF600Apr 22, 2024

  THIS DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THE ON-SITE INVESTIGATION Based on medical record review, staff interview, resident representative interview, law enforcement interview, review of facility self-reported incidents (SRIs), review of police reports, review of police body camera footage, review of emergency medical services (EMS) run reports, review of hospital records, review of the Facility Assessment, and review of facility policies, the facility failed to ensure Resident #1 was free from physical abuse from Resident #2. This resulted in Immediate Jeopardy and serious life-threatening harm on 03/12/24 at approximately 5:00 A.M. […]

• Immediate jeopardy, isolatedF689Sep 12, 2023

  Based on observation, record review, review of the facility Elopement/Unauthorized Absence policy and procedure and interviews, the facility failed to provide adequate supervision and individualized and comprehensive interventions to prevent Resident #101 from eloping from the facility. This resulted in Immediate Jeopardy and the likelihood of actual harm on 08/29/23 at approximately 9:48 A.M. when Resident #101, who was cognitively impaired and assessed to be at high risk for elopement, exited the facility grounds without staff knowledge, during a supervised smoke break. Staff failed to identify Resident #101 was missing until approximately 12:15 P.M. when the resident was not available for lunch. On 08/29/23 at 5:14 P.M. […]

• Actual harm, isolatedF690Apr 13, 2023

  Based on medical record review, review of hospital documentation and interview the facility failed to ensure Resident #138 was provided timely and adequate urinary catheter care to prevent a urinary tract infection. The facility also failed to timely re-assess Resident #54's need for an indwelling urinary catheter following an evaluation in the emergency room . Actual harm occurred on 03/04/23 when Resident #138, who was dependent on staff for all activities of daily living was transferred to the hospital and admitted with a urinary tract infection (UTI) requiring intravenous antibiotic treatment. […]

• Actual harm, isolatedF686Sep 9, 2021

  Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure adequate interventions were implemented to prevent the development of a pressure ulcer for Resident #3. Actual Harm occurred on 09/01/21 when Resident #3 who required extensive assistance from staff for bed mobility and transfers was found to have an unstageable pressure ulcer (a wound caused by pressure that had full thickness tissue loss in which the base of the ulcer was covered by slough (nonviable dead tissue that is white or yellow in appearance) or eschar (dead tissue that was usually black) to the left ischial lower and back part of his hip. […]

• No harm, potential for more than minimal, widespreadF814Sep 4, 2024

  Based on observation, interview and review of facility policy, the facility did not ensure garbage was properly disposed of to prevent the harborage pests. This had the potential to affect all 144 residents. The facility census was 144. Findings include: Observation on 08/28/24 at 9:30 A.M. with Maintenance Director #539 revealed the three outside dumpsters near the facility kitchen doors did not have lids covering trash, a sour smell permeated around the dumpsters with wet boxes and leaf and twig debris piled up around the dumpsters. Maintenance Director #539 verified the findings on 08/28/24 at 9:30 A.M. and stated it was difficult to get behind the dumpsters to pick up the boxes and clean the area, and there should be lids to cover the trash. […]