University Commons Nursing Care Center

Total Number of Beds: 164	Percent of Occupied Beds: 90%
Total Number of Residents: 148	Located Within a Hospital: No
Type of Ownership: Non profit - Corporation	Multiple Nursing Homes by Same Owner: No
Councils the Nursing Home Participates in: Family & Resident	Medicare/Medicaid: Participating in Medicare and Medicaid
* Details Last Reported on: 09/18/2003

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day: 0.83

Number of LPN/LVN Hours per Nursing Home Resident per Day: 0.64

Number of CNA Hours per Nursing Home Resident per Day: 2.45

Number of Staff Hours per Nursing Home Resident per Day: 3.92

Nursing Home Resident Information**:

Percent of Low-Risk Residents Who Have Pressure Sores: 0%
Percent of Short-Stay Residents With Pressure Sores: 15%
Percent of High-Risk Residents Who Have Pressure Sores: 13%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain: 33%
Percent of Residents Who Have Moderate to Severe Pain: 10%
Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse: 14%
Percent of Residents Who Spend Most of Their Time in Bed or in a Chair: 3%
Percent of Residents Whose Need for Help With Daily Activities Has Increased: 19%
Percent of Residents Who are More Depressed or Anxious: 14%
Percent of Short-Stay Residents With Delirium: 3%
Percent of Residents Who Were Physically Restrained: 6%
Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder: 45%
Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder: 7%
Percent of Residents With a Urinary Tract Infection: 10%
** Details Last Reported on: 9/18/2003

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2001-07-17	2001-10-03	Mistreatment Deficiencies	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Widespread	Potential for minimal harm
2001-07-17	2001-10-03	Resident Rights Deficiencies	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
2001-07-17	2001-10-03	Environmental Deficiencies	Keep adequate and comfortable lighting in all areas.	Pattern	Minimal harm or potential for actual harm
2001-07-17	2001-10-03	Resident Assessment Deficiencies	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Actual harm
2001-07-17	2001-10-03	Resident Assessment Deficiencies	Do a new assessment after any major change in a resident's physical or mental health.	Isolated	Actual harm
2001-07-17	2001-10-03	Resident Assessment Deficiencies	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Actual harm
2001-07-17	2001-10-03	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Actual harm
2001-07-17	2001-10-03	Resident Assessment Deficiencies	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Actual harm
2001-07-17	2001-10-03	Quality Care Deficiencies	Give professional services that follow each resident's written care plan.	Isolated	Actual harm
2001-07-17	2001-10-03	Resident Assessment Deficiencies	Electronically record and report resident status assessments in a timely manner as required in order to monitor resident health and progress.	Pattern	Potential for minimal harm
2001-07-17	2001-10-03	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
2001-07-17	2001-10-03	Quality Care Deficiencies	Make sure that each residents' abilities to take care of themselves does not lessen, unless a change cannot be avoided.	Isolated	Actual harm
2001-07-17	2001-10-03	Quality Care Deficiencies	Make sure that each resident gets help to keep vision and hearing.	Isolated	Minimal harm or potential for actual harm
2001-07-17	2001-10-03	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
2001-07-17	2001-10-03	Quality Care Deficiencies	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Actual harm
2001-07-17	2001-10-03	Quality Care Deficiencies	Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.	Isolated	Actual harm
2001-07-17	2001-10-03	Environmental Deficiencies	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
2001-07-17	2001-10-03	Quality Care Deficiencies	Make sure that each resident's nutritional needs were met.	Isolated	Actual harm
2001-07-17	2001-10-03	Quality Care Deficiencies	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Actual harm
2001-07-17	2001-10-03	Pharmacy Service Deficiencies	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Actual harm
2001-07-17	2001-10-03	Pharmacy Service Deficiencies	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
2001-07-17	2001-10-03	Nutrition and Dietary Deficiencies	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
2001-07-17	2001-10-03	Nutrition and Dietary Deficiencies	Provide food in a way that meets a resident's needs.	Isolated	Minimal harm or potential for actual harm
2001-07-17	2001-10-03	Nutrition and Dietary Deficiencies	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Widespread	Minimal harm or potential for actual harm
2001-07-17	2001-10-03	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
2001-07-17	2001-10-03	Pharmacy Service Deficiencies	Make sure that the pharmacist reports anything unusual to the doctor on duty and the director of nursing.	Isolated	Actual harm
2001-07-17	2001-10-03	Environmental Deficiencies	Provide at least one room to use as a dining room and for activities, that is a good size, with good lighting, airflow and furniture.	Pattern	Minimal harm or potential for actual harm
2001-07-17	2001-10-03	Administration Deficiencies	Get services outside the nursing home that meet professional standards.	Isolated	Minimal harm or potential for actual harm
2001-07-17	2001-10-03	Administration Deficiencies	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
2001-07-17	2001-10-03	Administration Deficiencies	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
2001-07-17	2001-10-03	Administration Deficiencies	Train all employees on what to do in an emergency.	Pattern	Minimal harm or potential for actual harm
2002-06-25	2002-09-18	Resident Rights Deficiencies	Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm
2002-06-25	2002-08-22	Resident Assessment Deficiencies	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Actual harm
2002-06-25	2002-08-22	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Actual harm
2002-06-25	2002-08-22	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
2002-06-25	2002-08-22	Quality Care Deficiencies	Make sure that residents with loss of bladder control receive treatment or service to prevent infections and help get normal bladder control.	Isolated	Minimal harm or potential for actual harm
2002-06-25	2002-08-22	Environmental Deficiencies	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
2002-06-25	2002-09-18	Quality Care Deficiencies	Make sure each resident is being watched and has assistance devices when needed, to prevent accidents.	Isolated	Actual harm
2002-06-25	2002-08-22	Quality Care Deficiencies	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Actual harm
2002-06-25	2002-08-22	Nutrition and Dietary Deficiencies	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
2002-06-25	2002-08-22	Resident Assessment Deficiencies	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
2002-06-25	2002-08-22	Administration Deficiencies	Set up or keep a group of people to review and ensure quality.	Widespread	Potential for minimal harm

*** All violations listed are based on federal government records.