University Post Acute

• Ownership

  CMS lists this home under a new chain.

CMS lists this as a standard inspection.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on December 11, 2025.

• Citation F0688. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on December 11, 2025.

• Citation F0912. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

  CMS lists it as corrected on December 11, 2025.

  CMS has cited this home for F0912 3 times since 2022.

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CMS lists this as a standard inspection.

• Citation K0293. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have properly located and lighted "Exit" signs.

  CMS lists it as corrected on December 25, 2025.

• Citation K0346. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Follow proper procedures when the fire alarm was out of service for more than 4 hours.

  CMS lists it as corrected on December 25, 2025.

• Citation K0353. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on December 24, 2025.

  CMS has cited this home for K0353 3 times since 2022.

• Citation K0354. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

  CMS lists it as corrected on December 24, 2025.

• Citation K0372. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on December 24, 2025.

• Citation K0920. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on December 24, 2025.

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• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 5 of 5.

CMS lists this as a complaint inspection.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on October 17, 2024.

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CMS lists this as a standard inspection.

• Citation F0641. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives an accurate assessment.

  CMS lists it as corrected on August 6, 2024.

  CMS has cited this home for F0641 2 times since 2022.

• Citation F0644. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  CMS lists it as corrected on August 6, 2024.

• Citation F0645. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: PASARR screening for Mental disorders or Intellectual Disabilities

  CMS lists it as corrected on August 6, 2024.

• Citation F0912. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

  CMS lists it as corrected on August 6, 2024.

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CMS lists this as a standard inspection.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on August 19, 2024.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on August 19, 2024.

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CMS lists this as a standard inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on February 8, 2022.

• Citation F0641. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure each resident receives an accurate assessment.

  CMS lists it as corrected on February 8, 2022.

• Citation F0646. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

  CMS lists it as corrected on February 8, 2022.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on February 8, 2022.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on February 8, 2022.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on February 8, 2022.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on February 8, 2022.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on February 8, 2022.

• Citation F0912. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

  CMS lists it as corrected on February 8, 2022.

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CMS lists this as a standard inspection.

• Citation E0031. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide emergency officials' contact information.

  CMS lists it as corrected on February 8, 2022.

• Citation K0223. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

  CMS lists it as corrected on February 8, 2022.

• Citation K0321. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on February 8, 2022.

• Citation K0353. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on February 8, 2022.

• Citation K0355. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on February 8, 2022.

• Citation K0918. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on February 8, 2022.

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