University Park Care Center

In the surveyor’s words

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

• Actual harm, isolatedF686Jun 11, 2024

  Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to treat and prevent pressure injuries for one (#42) of two residents out of 50 sample residents reviewed for pressure ulcers. Resident #42, who was dependent on staff for all care and mobility and was known to be at risk for skin breakdown, developed a stage 3 pressure injury on 5/20/24 at the facility. The resident's care plan for skin breakdown failed to include interventions for repositioning the resident frequently to avoid potential pressure injuries. Observations during the survey revealed staff were not repositioning Resident #42 frequently in order to keep the resident from developing further pressure injuries. […]

• Actual harm, isolatedF697Feb 21, 2024

  Based on record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences for two (#1 and #4) of three residents reviewed for pain management out of four sample residents. The facility failed to ensure Resident #1 was administered pain medication as ordered. The resident admitted to the facility from the hospital on 8/30/23 with acute compression fractures of the spine and increased back pain. […]

• Actual harm, isolatedF689Jan 8, 2024

  Based on interviews and record review, the facility failed to provide an environment as free of accident hazards as possible and ensure residents received adequate supervision and assistance devices to prevent accidents for one (#1) of three residents reviewed for accident hazards out of three sample residents. Resident #1 had a diagnosis of dementia with wandering and resided in a secure unit. Resident #1 sustained nine falls from 9/17/23 to 11/27/23. The facility failed to ensure appropriate interventions and adequate supervision were implemented to prevent major injuries, including a fracture of the left and right hips, which were sustained in two separate falls. […]

• No harm, potential for more than minimal, widespreadF880Jun 11, 2024

  Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on two of four units. Specifically, the facility failed to ensure glucometers were cleaned in a sanitary manner. Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC) Considerations for Blood Glucose Monitoring and Insulin Administration (2024), was retrieved on 6/18/24 from https://www.cdc.gov/injection-safety/hcp/infection-control/index.html#:~:text=Unsafe%20practices%20during%20assisted%20monitoring,for%20more%20than%20one%20person. […]

• No harm, potential for more than minimal, patternF880Aug 27, 2026

  Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on one of four units.Specifically, the facility failed to:-Ensure resident rooms were cleaned in a hygienic manner; -Ensure staff wore appropriate personal protective equipment (PPE) when providing care to a Resident #14, who was on enhanced barrier precautions (EBP); and, -Ensure staff performed hand hygiene while assisting residents with meals. Findings include: I. Failed to ensure resident rooms were cleaned in a hygienic manner. A. […]