Urbana Health & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF880Mar 15, 2021

  Based on medical record review, observation, interviews with staff and the Medical Director, review of the facility's policy, review of the manufacturer instructions for use of the glucometer, and review of the Centers for Disease Control and Prevention (CDC) guidance on infection control during blood glucose monitoring and on [MEDICAL CONDITION], the facility failed to implement an infection control protocol to prevent the potential indirect transmission of a bloodborne pathogen, [MEDICAL CONDITION], to residents who had finger stick blood sugar testing performed utilizing a shared glucose monitoring device (glucometer). The glucometer was not properly cleaned and disinfected between residents and the nurse did not perform proper hand hygiene practices between residents. […]

• No harm, potential for more than minimal, patternF565Jun 10, 2025

  Based on review of the Resident Council Minutes, staff and resident interview, and policy review, the facility failed to ensure resident concerns were addressed in a timely manner or resolved. This affected three (#24, #35, #29) of three residents who attended a surveyor led Resident Council Meeting during the annual survey. The facility identified there were 13 residents who regularly attend resident council meetings. This had the potential to affect all of the residents who reside in the facility. The census was 46. […]

• No harm, potential for more than minimal, patternF759Jun 10, 2025

  Based on observation, record review, staff interview, and facility policy review, the facility failed to have a medication error rate less than five percent. This affected two residents (#15 and #43) of three residents observed for medication administration. The facility census was 46. Findings Included: Observation on 06/04/25 of medication pass revealed 30 opportunities were observed with two errors for a medication error rate of 6.67%. 1. Review of medical records for Resident #43 revealed an admission date 07/18/24. Diagnoses included chronic obstructive pulmonary disease, osteoporosis, pneumonia, paroxysmal atrial fibrillation. […]

• No harm, potential for more than minimal, patternF804Jun 10, 2025

  Based on observations, record review, staff interviews and facility policy review, the facility failed to prepared palatable food. This affected 29 residents, (#20, #39, #35, #5, #28, #2, #34, #12, #33, #198, #38, #8, #17, #27, #43, #29, #3, #13, #32, #198, #22, #10, #26, #31, #25, #24, #7, #23, and #37) who were served regular consistency textured diets. The facility census was 46. Findings Include: Review of medical records revealed the following residents had a physician order for a regular consistency textured diet, Resident #20, #39, #35, #5, #28, #2, #34, #12, #33, #198, #38, #8, #17, #27, #43, #29, #3, #13, #32, #198, #22, #10, #26, #31, #25, #24, #7, #23, and #37. Observation on 06/02/25 at 11:46 A.M. […]

• No harm, potential for more than minimal, patternF812Jun 10, 2025

  Based on observations, staff interviews, record reviews, and facility policy review, the facility failed to prepare food in a sanitary manner. This affected 45 residents who received food from the kitchen. The facility census was 46. Findings Include: 1. Observation on 06/02/25 at 10:05 A.M. of Diet Manger, (DM) #208 revealed white flakes of skin surrounded with bright reddened ring of skin on bilateral underside of forearms, measuring approximately four inches by two inches. When DM #208 touched the skin areas, flaky skin was removed. Interview on 06/02/25 at 10:05 A.M. with DM #208 verified the skin areas were diagnosed as a noncommunicable skin condition. DM #208 verified the skin areas should be covered due to the flaky skin. […]