University Post-Acute Rehab

In the surveyor’s words

From the most serious findings on record at University Post-Acute Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Jan 13, 2022

  Based on observation, interview and record review, the facility failed to ensure infection prevention and control guidelines were maintained for a census of 41, when: 1. Several urinals for three residents were not labeled or dated; 2. Licensed Nurse (LN) did not sanitize blood pressure cuff before use, and did not wear gloves when providing care to resident; 3. Drinks were found in the laundry room; and 4. Nasal cannula was found on the floor. These failures had the potential to result in transmission of infection in a vulnerable population. Findings: 1. During an observation on 1/10/22 at 9:05 a.m., a urinal was found on top of the night stand of Resident 15. […]

• No harm, potential for more than minimal, patternF656May 22, 2025

  Based on interview and record review, the facility failed to ensure care plans (a summary of a person's health conditions, specific care needs, and current treatments) were developed for three of 19 sampled residents (Resident 14, Resident 17, and Resident 27) when: 1. Resident 14 had no anticoagulant (a medicine that help prevent blood clots) monitoring care plan; 2. Resident 17 had no bed alarm and wheelchair alarm (pads that contains sensors that trigger an alarm when they detect a change in pressure) monitoring care plan; and, 3. Resident 27 had no bed alarm monitoring care plan. These failures had the potential to result in inaccurate and inadequate care being provided to Resident 14, 17, and 27. Findings: 1. […]

• No harm, potential for more than minimal, patternF759May 22, 2025

  Based on observation, interview, and record review, the facility failed to ensure the medication rate did not exceed 5% (percent, unit of measure) for two of three sampled residents (Resident 302 and Resident 40). 1. For Resident 302, a Licensed Nurse (LN) did not administer resident's lidocaine patch (medication patch used to treat pain) 5 % as it was prescribed by the doctor. 2. For Resident 40, an LN did not administer resident's finasteride (hazardous medication used to treat an enlarged prostrate) 5 mg (milligram, unit of measure) as prescribed by the doctor. These failure resulted in a medication error rate of 6.45 % with two errors occurring out of 31 opportunities during the observation of medication administration. Findings: 1. […]

• No harm, potential for more than minimal, patternF761May 22, 2025

  Based on observation, interview, and record review, the facility failed to ensure medications were stored correctly, when: 1. The medication refrigerator temperature was out of range in the medication room which put medication requiring specific temperature at risk of degradation, 2. Resident 36's opened inhaler (used to administer medication by breathing in) in the medication cart 1 was not dated when opened, which put Resident 36 at risk of receiving ineffective expired or outdated medication, 3. An opened, undated multidose container of glucose test strip was found in medication cart 1, which had the potential risk of using expired, or inaccurate glucose test strips to monitor resident's blood glucose levels. […]

• No harm, potential for more than minimal, patternF806May 22, 2025

  Based on observation, interview, and record review, the facility failed to provide alternative meal options of similar protein/calorie value to the meal entrée when grilled cheese sandwich or cheese quesadilla were provided in place of the entree. This failure had the potential of leading to protein/calorie malnutrition for those choosing these alternatives for census of 50. Findings: During the initial kitchen tour on 5/19/25 at 8:15 a.m., the alternative menu was observed hanging in the kitchen over the preparation counter. This menu included the option of a grilled cheese sandwich as an alternate meal. During an observation of the lunch meal plating on 5/20/25 at 12:10 p.m., a cheese quesadilla was prepared as an alternative to the main entrée. […]