University Nursing & Rehab Center

In the surveyor’s words

From the most serious findings on record at University Nursing & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, patternF678Jun 20, 2022

  Based on record review, interviews, and policy review, the facility failed to accurately assess the Advance Directive status and provide Cardiopulmonary Resuscitation (CPR) to prevent death when a resident was found without a pulse or respirations for 4 of 4 residents (R) (R#243, R#141, R#191, and R#291) reviewed with a full code status who expired in the last six months. R#243, R#141, and R#291 had a full code status, as directed by the residents' POLST (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812May 14, 2026

  Based on observations, staff interview, and review of the facility's policy titled DATING AND LABELING POLICY, the facility failed to ensure that food items were properly labeled, dated, and discarded in accordance with facility policy to prevent potential foodborne illness. This deficient practice had the potenitial to affect all 98 residents receiving an oral diet.Findings include:During tour of the kitchen on 05/11/2026 from 9:40 AM to 10:00 AM, and interview with the Dietary Manager (DM) revealed the following concerns:Observation of the walk-in freezer revealed a bag with french toast with use by date of 05/7/2026, a bag with hash brown patties, dated 04/19 with no use-by date indicated, a plastic-wrapped hash brown patties labeled with an open date of 04/19 with no use-by date… […]

• No harm, potential for more than minimal, widespreadF812Apr 3, 2025

  Based on observations, interviews, and cleaning schedule review, the facility failed to maintain the cleanliness of the kitchen creating the potential for contaminated food to be served to 97 of 102 residents that received an oral diet. Findings include: 1. During the initial tour of the kitchen and interview on 3/31/2025 from 8:30 am to 9:15 am, the following was observed: a. The floor in the dish room was missing a section of tiles which measured approximately 11 inches by six inches making it an uncleanable surface. Several more tiles were missing underneath the counter in the dish room. The wall underneath the counter had a dark black substance on the entire wall. The Dietary Manager (DM) stated, We try to clean the wall with a power washer each week. It [wall] needs to be replaced. b. […]

• No harm, potential for more than minimal, widespreadF880Dec 9, 2023

  Based on observations, record review, staff and resident interviews, and review of the facility policies titled, Infection Prevention and Control Program and Cleaning and Disinfection of Resident-Care Items and Equipment, the facility failed to maintain proper infection control and prevention in 11 of 46 resident rooms (17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27) related to storage of resident personal care items. In addition, the facility failed to adhere to and to serve food to residents in isolation using transmission-based precautions (TBP). The deficient practice had the potential to affect all facility residents by exposing them to infection. The facility census was 90. […]

• No harm, potential for more than minimal, widespreadF881Dec 9, 2023

  Based on observations, record review, staff and resident interviews, and review of the facility policies titled, Infection Prevention and Control Program and Antibiotic Stewardship, the facility failed to establish an infection prevention and control program that included an Antibiotic Stewardship Program with included antibiotic use protocols and a system to monitor antibiotic use for four of 27 sampled residents (R) (R77, R38, R58, and R83). This deficient practice had the potential to affect all residents that receive antibiotics. The facility census was 90. Findings include: Review of the facility policy titled, Infection Prevention and Control Program with a revision date of September 2023 revealed: 3. Surveillance a. […]