University Place Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF925Sep 20, 2021

  Based on observations, record reviews, and staff, resident, pest control technician and physician interviews, the facility failed to implement an effective pest control program to control the presence of flies in the room of 1 of 3 sampled residents (Resident #1). Resident #1 had live maggots develop in her right heel wound. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including non-Alzheimer's dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and required total assistance with all activities of daily living. The MDS also indicated she had pressure ulcers on the sacrum, left heel and right heel which required treatments. […]

• Actual harm, patternF679Mar 13, 2024

  Based on record review, facility activity calendar, and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 4 of 5 residents reviewed for activities (Resident #17, 31, 35, and 110). The residents expressed not being able to leave the facility for over a year made them feel more dependent, less social, sad, and they missed getting out with the group to shop and socialize. The findings included: A review of the February 2024 activity calendar revealed activities for inside of the facility during the week and on the weekends. […]

• Actual harm, isolatedF760Oct 15, 2024

  Based on observations, record review, and staff, Resident Representative, Physician Assistant and Pharmacist interviews, the facility failed to ensure a resident was free of significant medication errors when they failed to administer a daily dose of Cenobamate (seizure medication) from 9/05/24 through 9/18/24. Resident #1 was observed having a mild seizure (eyes rolled back and upper body twitching that lasted approximately 2 minutes) on 9/18/24. This deficient practice occurred for 1 of 3 residents reviewed for medication errors. (Resident #1) The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included seizure disorder. The neurology visit note dated 8/06/24 revealed Resident #1 was experiencing persistent break through seizures. […]

• No harm, potential for more than minimal, patternF812Jul 24, 2025

  Based on observations and staff interviews, the facility failed to remove a dented can located on shelf ready for use and failed to reseal and label and date leftover food items stored for use. These practices occurred in 1 of 1 walk-in freezer and 1 of 1 dry storage room and had the potential to affect food served to residents. The findings included: An initial tour of the kitchen occurred on 7/21/25 at 10:09 AM. The following concerns were identified:a. Items in the walk-in freezer that were open to air and not resealed but labeled included: -one 15.33 pound (lb.) box of Texas Toast bread, dated 7/11/25-one 7.93lb box of churros, dated 10/24/25 Items in the walk-in freezer that were open to air, not resealed, and not labeled included:-one18.9lb box of [NAME] cheese omelets -one 20lb box… […]

• No harm, potential for more than minimal, patternF842Oct 15, 2024

  Based on record review, and staff interviews, the facility failed to accurately document the administration of 14 doses of a seizure medication in the medical record for 1 of 1 resident reviewed for accurate medical records (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included seizure disorder. The neurology visit note dated 8/06/24 revealed Resident #1 was experiencing persistent break through seizures. Resident #1 was ordered to start Cenobamate once a day at bedtime with a gradual dose increase to 100 mg. A review of Resident #1's physician orders revealed the following orders: Cenobamate 50 mg to be administered once a day at bedtime 9/05/24 through 9/18/24. […]