University Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 11, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one of thirteen residents (Resident #12) reviewed for accidents and hazards.The facility failed to ensure Resident #12 received the appropriate supervision to prevent elopement from the facility on 6/23/2025 and 07/13/2025.The non-compliance was identified as PNC on 09/11/25 and the IJ template was provided the facility on 09/11/25 at 3:10 PM. The noncompliance began on 07/13/2025 and ended 07/13/2025. The facility corrected the non-compliance before the survey began.These failures could place the residents at risk of serious harm, injury and death from wandering outside the facility in unfamiliar surroundings. . […]

• Immediate jeopardy, isolatedF684Feb 28, 2024

  Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Residents #11 and #49) of 7 residents reviewed for quality of care. 1. LVN D failed to order xrays for Resident #11 after she fell on [DATE] and complained of right-side pain. The xrays were not completed until the next day 12/17/23 the resident was diagnosed with fractures of the 8th to 10th ribs. 2. The facility failed to assess and document Resident #49's injury to her right ankle on 01/23/24, when therapy heard an audible sound when he attempted to put her shoe back on. […]

• Immediate jeopardy, isolatedF776Feb 28, 2024

  Based on observation, interview and record review the facility failed to provide radiology or other diagnostic services to meet the needs of its residents in a timely manner for 2 (Resident #11 and #49) of 7 residents reviewed for radiology services. 1. LVN D failed to order xrays for Resident #11 after she fell on [DATE] and complained of right-side pain. The xrays were not completed until the next day 12/17/23 and the resident was diagnosed with fractures of the 8th to 10th ribs. 2. The facility failed to obtain timely radiology services on 01/23/24, after the Physical Therapist reported to the nurse that Resident #49 had an audible sound to her right ankle and was noted to be in an unusual position. […]

• Immediate jeopardy, isolatedF580Dec 2, 2022

  Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status and a need to alter treatment significantly for 2 (Resident #32 and #29) of 8 residents reviewed for physician notification. The facility failed to ensure: 1. LVN B immediately notified Resident #32's physician when Resident #32, who did not have a history of shortness of breath complaints, complained of not being able to breathe and requested two breathing treatments the night of [DATE]. Resident #32 was discovered on [DATE] unresponsive and not breathing. CPR was preformed but she was pronounced dead at the facility on [DATE]. 2. […]

• Immediate jeopardy, isolatedF684Dec 2, 2022

  Based on observations, interviews, and records reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Resident #32 and Resident #29) of 8 residents reviewed for quality of care. The facility failed to ensure: 1. Resident #32 was appropriately assessed, monitored, and care plans were followed when Resident #32, who did not have a history of shortness of breath complaints, complained of not being able to breathe and requested two breathing treatments the night of [DATE]. Resident #32 was discovered on [DATE] unresponsive and not breathing. CPR was preformed but she was pronounced dead at the facility on [DATE]. 2. […]