University Park Rehabilitation and Healthcare

In the surveyor’s words

From the most serious findings on record at University Park Rehabilitation and Healthcare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 12, 2026

  Based on interview and record review, the facility failed to ensure accident prevention interventions were implemented for 1 of 2 residents reviewed for accidents. A resident exited the facility unattended, his whereabouts unknown for approximately 13 hours. He was not noticed to be missing until an hour and half before being found approximately 1 mile away from the facility. (Resident B).Findings include:The Immediate Jeopardy began on 5/19/26 when Resident B was last seen about 1:00 a.m. and reported missing at 2:00 p.m. the next day. He was located at 3:15 p.m., approximately 1 mile from the facility on sidewalk of busy 6 lane highway with a speed limit of 45 mph. […]

• Immediate jeopardy, isolatedF689Feb 14, 2024

  Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent unsupervised smoking inside the facility and failed to ensure hazardous smoking materials were not accessible to residents who required supervised smoking for 1 of 3 residents reviewed for smoking (Resident B). The Immediate Jeopardy began on 1/30/24 when Resident B was observed with cigarettes and lighter smoking in her room. Unsupervised smoking could result in fire or burn injury to herself and other residents residing in the facility. The Chief Operating Officer (COO), Chief Nursing Officer (CNO), Regional Director of Operations (RDO), and Director of Nursing (DON) were notified of the Immediate Jeopardy on February 13, 2024 at 1:39 P.M. […]

• No harm, potential for more than minimal, widespreadF812Feb 19, 2026

  Based on observation, interview, and record review, the facility failed to ensure monitoring of adequate hypochlorite (sanitizer) use in the facility dishwasher and sanitary food handling during food service. 82 of 82 residents residing in the facility were served food prepared in the facility kitchen. Findings include:1) During a kitchen tour, on 02/15/2026 10:00 AM, Dietary Aide (DA) 2 was observed pulling a rack of wet dishes out of the dishwasher and reloading the dishwasher with dirty dishes. In an observation, on 02/15/2026 10:18 AM, DA 2 and DA 4 were in the dish room washing dishes, with 3 racks of wet dishes observed in the clean area. The Dietary Manager (DM) dipped a test strip into the filled dishwasher testing well during the sanitizing cycle. […]

• No harm, potential for more than minimal, widespreadF727Apr 11, 2025

  Based on observation, interview and record review, the facility failed to ensure a registered nurse was on duty for 8 consecutive hours every day. 65 residents resided at the facility. Findings include: On 4/11/25 at 10:14 AM, a review of the as worked nursing schedule, dated 4/3/25 through 4/10/25, indicated the following: On 4/4/25, Registered Nurse (RN) 4 clocked in at 8:44 AM and clocked out at 2:10 PM. On 4/5/25, RN 4 clocked in at 9:49 AM and clocked out at 2:05 PM. On 4/7/25, RN 4 clocked in at 11:20 AM and clocked out at 2:41 PM. In an interview, on 4/11/25 at 10:51, the Director of Nursing (DON) indicated RN 4 was the only RN scheduled on 4/4/25 and 4/7/25. The DON indicated they had split the shift with RN 4 on 4/5/25. […]

• No harm, potential for more than minimal, widespreadF812Apr 11, 2025

  Based on observation, interview and record review the facility failed to ensure open items in the kitchen and unit refrigerators were labeled, dated, discarded when appropriate, and hair was covered for all employees present in the kitchen. 65 of 65 residents residing in the facility were served food prepared in the kitchen. Findings include: During an observation, on 4/7/25 at 9:16 AM, a container of a brown lumpy substance covered with clear plastic wrap and a plastic bag of parsley with its original seal opened, twist ied shut were observed on a shelf in the walk-in cooler. Neither item was labeled or dated. A container of strawberries soaking in red liquid on a shelf in the cooler was dated 3/28. […]