University Place Health Center and Assisted Living

In the surveyor’s words

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

• Actual harm, isolatedF689Mar 31, 2026

  Based on interview and record review, the facility failed to ensure a resident was kept safe during a transfer by a staff member for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B sustaining a minimally displaced oblique fracture of the mid tibial diaphysis (a stable, angled break in the middle shaft of the shinbone) and a minimally displaced spiral fracture of the proximal fibular diaphysis (a stable, low-energy injury near the knee). […]

• No harm, potential for more than minimal, patternF692Dec 1, 2023

  Based on observation, interview and record review, the facility failed to notify the physician of significant weight changes for 4 of 6 residents reviewed for nutrition. (Residents 24, 10, 14, and 18) Findings include: 1. The record for Resident 24 was reviewed on 11/29/23 at 2:08 p.m. Diagnoses included, but were not limited to, type 2 diabetes, cellulitis, morbid obesity, and chronic kidney disease stage 3. A weight log indicated the following: On 10/2/23, the resident weighed 317 pounds. On 10/9/23, the resident weighed 319.2 pounds. On 11/1/23, the resident weighed 329.4 pounds. On 11/22/23, the resident weighed 343.6 pound. There was a significant weight gain of 8.3%, from 10/2/23 to 11/22/23, in 51 days. […]

• No harm, potential for more than minimal, isolatedF644Nov 25, 2025

  Based on interview and record review, the facility failed to ensure the Preadmission Screening and Record Review (PASARR) screenings were accurate when completed and updated when new mental health diagnoses and medications were initiated for 2 of 2 residents reviewed for PASARR. (Resident 3 and 19)Findings include: 1. The clinical record for Resident 3 was reviewed on 11/24/25 at 11:24 a.m. The diagnoses included, but were not limited to, Parkinson's disease, dementia, anxiety, depression, and a psychotic disorder not due to a substance or known physiological condition. […]

• No harm, potential for more than minimal, isolatedF677Nov 25, 2025

  Based on observation, interview and record review, the facility failed to ensure a resident received assistance with personal hygiene for 1 of 2 residents reviewed for activities of daily living (ADL) care. (Resident 29)Findings include:During an interview, on 11/24/25 at 10:24 a.m., Resident 29's representative voiced concerns about Resident 29's showers. She indicated she had called the facility and asked if the resident received her shower. The staff indicated Resident 29 received one regularly. When the family visited the resident, the resident often had greasy hair and appeared dirty. When family questioned staff about the resident's appearance, staff indicated the resident had behaviors and they could not give her a shower. […]

• No harm, potential for more than minimal, isolatedF684Nov 25, 2025

  Based on interview and record review, the facility failed to ensure a daily weight was obtained as ordered by the physician for 1 of 1 resident reviewed for edema. (Resident 6) Findings include:The clinical record for Resident 6 was reviewed on 11/24/25 at 12:31 p.m. The diagnoses included, but were not limited to, chronic congestive heart failure, atrial fibrillation, and hypertension. A physician's order, dated 11/8/25, indicated to obtain daily weights. The clinical record indicated a daily weight was missing on 11/14/25.The clinical record indicated, on 11/19/25, Resident 6 had a weight gain of 4.4 pounds in one day. A care plan, dated as revised on 11/18/25, indicated the resident had altered cardiovascular status. […]