University Heights Care Center

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Emergency Preparedness Deficiencies

Include a process for Emergency Preparedness collaboration.

Emergency Preparedness Deficiencies

Develop Emergency Preparedness policies and procedures.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Deficiency cited from Occurrence #s 24020447029, 24020447030, 24020447033, 24020447047, 24020447055, and 24020447057. The facility failed to provide additional information as requested for six Occurrence events submitted through the Department' s COHFI system. Findings include: 1. On 6/1/24, the facility submitted a report for a Physical Abuse event - report 24020447029. After reviewing the report, additional information was needed to complete the review of the event. Attempts to contact a facility representative occurred via phone messages, external emails and COHFI messages on the following dates: 2/12/25, 3/4/25, 4/16/25, 4/18/25, 4/24/25 and 4/30/25. The COHFI messages remain unopened and unread. There was no response to voicemail or email messages. 2. On 6/2/24, the facility submitted a report for a Physical Abuse event - report 24020447030. After reviewing the report, additional information was needed to complete the review of the event. Attempts to contact a facility representative occurred via phone messages, external emails and COHFI messages on the following dates: 2/12/25, 3/4/25, 3/10/25, 4/16/25, 4/18/25, 4/24/25 and 4/30/25. The COHFI messages remain unopened and unread. There was no response to voicemail or email messages. 3. On 7/8/24, the facility submitted a report for a Neglect event - report 24020447033. After reviewing the report, additional information was needed to complete the review of the event. Attempts to contact a facility representative occurred via phone messages, external emails and COHFI messages on the following dates: 2/12/25, 3/4/25, 3/10/25, 4/16/25, 4/18/25, 4/24/25 and 4/30/25. The COHFI messages remain unopened and unread. There was no response to voicemail or email messages. 4. On 10/15/24, the facility submitted a report for a Sexual Abuse event - report 24020447047. After reviewing the report, additional information was needed to complete the review of the event. Attempts to contact a facility representative occurred via phone messages, external emails and COHFI messages on the following dates: 3/5/25, 3/10/25, 4/16/25, 4/18/25, 4/24/25 and 4/30/25. The COHFI ..

A complaint survey, prompted by #CO39568 and Incident #39506, Incident #39509, Incident #39511, Incident #39512 and Incident #39513 was conducted on 3/25/25 to 3/26/25. Three deficiencies were cited. Based on observations, record review and interviews, the facility failed to ensure one (#2) of five residents out of 13 sample residents who were diagnosed with dementia, received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being.Specifically, the facility staff failed to implement person-centered interventions to prevent Resident #2 from displaying physically aggressive behaviors toward other residents related to her diagnosis of dementia.Findings include: I. Facility policy and procedureThe Dementia-Clinical Protocol policy and procedure, dated 2/29/24, was provided by the nursing home administrator (NHA) on 3/27/25 at 2:30 p.m. It revealed in pertinent part, "The staff will review the current physical, functional, and psychosocial status of individuals with dementia, and will summarize the individual' s condition, related complications, and functional abilities and impairments. "The IDT (interdisciplinary team) will identify a resident-cen.. Based on record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#4) of three residents reviewed for accidents out of 12 sample residents.Specifically, the facility failed to:-Ensure Resident #4 was provided with the supervision necessary to prevent elopement; and,-Ensure Resident #4' s elopement on 3/2/25 was investigated thoroughly.Findings include:I. Facility policy and procedureThe Elopement and Wandering policy and procedure, dated 2/29/24, was provided by the nursing home administrator (NHA) on 3/26/25 at 3:36 p.m. It read in pertinent part, "It is a goal of the facility to provide a safe environment using the least restrictive measures available in care for residents who are exhibiting elopement behavior."' Elopers' are defined as residents who make an overt or purposeful attempt to leave the facility and do not have the ability to identify safety risks."II. Resident #4A. Resident statusResident #4, age less than 65, was admitted on 9/13/24. According to the Marc.. Based on record review and interviews, the facility failed to ensure three (#13, #1 and #6) of five residents out of 13 sample residents were kept free from abuse.Specifically, the facility failed to:-Ensure Resident #13 and Resident #1 were kept free from physical abuse by Resident #2; and,-Ensure Resident #6 was kept free from physical abuse by Resident #7.Findings include: I. Facility policy and procedureThe Abuse policy and procedure, dated 2/29/24, was provided by the nursing home administrator (NHA) on 3/27/25 at 2:30 p.m. It revealed in pertinent part, "Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment and willful neglect of the resident' s basic needs. "The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal g..