Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at University Place Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a seizure disorder did not receive their prescribed Cenobamate medication for 14 days, leading to a mild seizure. The medication was not available on the cart, and nurses on the second shift were unaware of its absence, failing to notify the pharmacy. This oversight was due to a lack of adherence to the 6 rights of medication administration.
A resident with a seizure disorder did not receive the prescribed doses of Cenobamate due to a failure in requesting the medication from the pharmacy. Despite this, two nurses documented the administration of the medication on the MAR, unaware that it was unavailable on the medication cart. The discrepancy was discovered during an investigation initiated by the ADON and Administrator.
A medication handling error occurred when a nurse failed to properly dispose of a plastic bag used to crush medications, leading to a resident mistakenly sprinkling the contents on his breakfast. The resident, who was cognitively intact, realized the bitter taste and spit it out, avoiding ingestion. The bag was intended for another resident with severe cognitive impairment. The nurse claimed the bag was empty, and staff interviews revealed a lack of awareness and communication about the incident.
A resident with a mechanical soft diet order due to dysphagia and other conditions repeatedly received crispy bacon, which was not ground as required. Despite the resident's complaints and the staff's awareness of his dietary needs, the tray card was never corrected, leading to the resident receiving inappropriate meals. Interviews with staff revealed a lack of communication and documentation regarding the resident's dietary preferences and education on the risks of eating crispy bacon.
A resident with a regular diet and mechanical soft texture preference did not receive scrambled eggs for breakfast as documented on his tray card. Despite attending Food Committee Meetings, his preference was not consistently honored, particularly when cheese eggs or an omelet were served. Staff interviews revealed awareness of his preference, but an oversight led to the resident receiving a cheese omelet instead, which he did not prefer.
A resident with severe cognitive impairment and a history of falls was transferred by a single nurse aide without the required mechanical lift, contrary to the care plan. The aide, an agency staff member, was not properly informed about the resident's transfer needs, leading to a deficiency in accident prevention and supervision.
The facility failed to assess two residents for the ability to self-administer medications. One resident was found with medications left on their overbed table, and another had a bottle of antacid chewable tablets. Both incidents were against the facility's policy, and neither resident had been assessed for self-administration.
The facility failed to provide adequate nail care for two dependent residents, resulting in long, dirty fingernails. Despite being scheduled for regular showers and requiring substantial assistance for personal hygiene, staff inconsistencies and a lack of monitoring led to the deficiency.
The facility failed to accurately code MDS assessments for several residents, leading to discrepancies in PASRR levels and restraint usage. Errors were attributed to human oversight and staff changes, with the Administrator and DON acknowledging the need for corrections.
The facility failed to properly label and store insulin pens, with observations revealing missing open dates, expired insulin, and improper storage. Nurses were unaware of their responsibilities, and the DON confirmed the expected procedures were not followed.
The facility failed to remove expired food items and unlabeled personal items from a resident's nourishment room. An 8 oz. fat-free milk with an expired best-by date and three unlabeled lunch bags were found in the memory care unit nourishment room. Staff had been educated not to store personal items in the nourishment room and to discard expired items, but these practices were not followed.
The facility's QAA committee failed to maintain procedures and monitor interventions, leading to repeat deficiencies in MDS coding, food sanitation, and infection control. Inaccurate MDS assessments were found for several residents, and expired and unlabeled food items were discovered in nourishment rooms. Additionally, staff did not follow proper hand hygiene and infection control practices during wound care and incontinence care.
The facility failed to complete PASRR Level II for three residents with mental health diagnoses, including delusional disorder, severe dementia with psychotic disturbance, dementia with mood disturbance disorder, and major depressive disorder. The Social Worker and Administrator acknowledged the oversight and confirmed that the assessments should have been completed in a timely manner.
Failure to Administer Seizure Medication Leads to Resident Seizure
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when they did not administer a daily dose of Cenobamate, a seizure medication, from September 5 through September 18. This lapse in medication administration led to the resident experiencing a mild seizure on September 18, characterized by eyes rolling back and upper body twitching lasting approximately two minutes. The resident had been admitted with a diagnosis of seizure disorder and had persistent breakthrough seizures, necessitating a specific medication regimen. The resident's medication orders included a gradual increase in Cenobamate dosage, which was not followed due to the medication not being available on the medication cart. Nurses on the second shift, who were responsible for administering the medication, were unaware that Cenobamate was missing and assumed it had been given. They did not identify the absence of the medication, nor did they notify the pharmacy to request the required doses. This oversight was compounded by a lack of adherence to the 6 rights of medication administration, which include verifying the right resident, drug, dosage, route, time, and documentation. Interviews with nursing staff revealed a misunderstanding of responsibilities regarding medication availability and administration. The facility's investigation determined that the error occurred because the increased doses of Cenobamate were never requested from the pharmacy. The resident's seizure on September 18 prompted a review of the medication administration process, revealing that the medication had not been administered as ordered, leading to the significant medication error.
Failure to Document Seizure Medication Administration
Penalty
Summary
The facility failed to accurately document the administration of a seizure medication, Cenobamate, for a resident diagnosed with a seizure disorder. The resident was supposed to receive Cenobamate 50 mg daily at bedtime from September 5 to September 18, followed by an increased dose of 100 mg starting September 19. However, a review of the Medication Administration Record (MAR) indicated that the medication was documented as given during this period, despite the controlled substance count sheet showing the last pill was administered on September 4. This discrepancy was discovered when the Assistant Director of Nursing (ADON) was informed by a nurse that the medication was not available on the cart, prompting an investigation. Interviews with the involved nurses revealed that they were unaware of the medication's unavailability and had mistakenly documented its administration on the MAR. The ADON and the Administrator confirmed that the medication was not requested from the pharmacy when the dose was increased, leading to the medication not being available for administration. The nurses involved were unable to explain why they documented the administration of a medication that was not present, highlighting a failure in maintaining accurate medical records and safeguarding resident-identifiable information.
Medication Handling Error Involving Two Residents
Penalty
Summary
The facility failed to properly dispose of a plastic bag used to crush medications, which led to a medication error involving two residents. Resident #23, who was cognitively intact and frequently reported severe pain, mistakenly believed the crushed medication in the bag was powdered sugar and sprinkled it on his breakfast. Upon tasting the bitter substance, he realized it was not sugar and spit it out, avoiding ingestion. The plastic bag had another resident's name on it, indicating it was intended for Resident #24, who was severely cognitively impaired and had no signs of pain. Nurse #1, who was responsible for administering medications, had crushed acetaminophen tablets for Resident #24 and placed the used plastic bag in her pocket instead of disposing of it properly. While assisting with breakfast tray distribution, the bag accidentally fell onto Resident #23's tray. Nurse #1 later realized the bag was missing and found it in Resident #23's room. Despite the incident, Nurse #1 claimed the bag was empty and had already administered the medication to the correct resident. Interviews with staff, including the DON, Unit Manager, and former Social Worker, revealed a lack of awareness and communication regarding the incident. The DON was informed by Nurse #1 that the bag was empty, and no further action was taken. The Unit Manager and former Social Worker were not fully aware of the details or the handling of the situation. The Physician Assistant confirmed that an extra dose of acetaminophen would not have caused harm to Resident #23, but the incident highlighted a lapse in medication handling procedures.
Failure to Provide Appropriate Diet for Resident with Mechanical Soft Texture Order
Penalty
Summary
The facility failed to provide food in a form that met the individual needs of a resident with a physician order for a regular diet with mechanical soft texture. The resident, who had diagnoses including dysphagia, dementia, and a cognitive communication deficit, was observed not eating his breakfast because it included crispy bacon, which was not ground as required by his diet order. Despite the resident's repeated complaints about receiving bacon that he could not eat due to his swallowing difficulties, the issue persisted, and his tray card incorrectly recorded a preference for crispy bacon. The resident expressed that he had been receiving bacon inappropriately for years, despite his diet order for ground meat. He stated that he could not eat the bacon because it was too hard and large, causing him to cough. The resident also mentioned that he had never requested crispy bacon and preferred to avoid pork. Staff interviews revealed that although some staff members were aware of the resident's dietary needs, the tray card was never corrected, and the resident continued to receive inappropriate meals. Interviews with various staff members, including a nurse aide, unit manager, speech therapist, certified foodservice manager, registered dietitian, and the administrator, highlighted a lack of communication and documentation regarding the resident's dietary needs and preferences. The speech therapist and registered dietitian confirmed that the resident should have been educated on the risks of eating crispy bacon, but there was no documentation of such education. The facility's failure to provide the resident with the appropriate diet as ordered by his physician resulted in the deficiency noted in the report.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to provide a resident with scrambled eggs for breakfast according to his preference, as documented on his tray card. This deficiency was identified for a resident who had a physician order for a regular diet with mechanical soft texture and was at risk for nutritional decline due to a history of weight loss and varying appetite. Despite attending weekly Food Committee Meetings, the resident expressed that his preference for scrambled eggs was not consistently honored, particularly when the menu included cheese eggs or an omelet. On the day of observation, the resident received a cheese omelet instead of scrambled eggs, which he did not prefer, leading to him not finishing his meal. Interviews with staff revealed that the resident's preference for scrambled eggs was known, but not always provided. A nurse aide familiar with the resident's preferences stated that she would return his tray to the kitchen if it did not meet his dietary needs, but she did not set up his tray on the day in question. The Unit Manager, who was not familiar with the resident's care needs, did not notice the discrepancy. The Certified Foodservice Manager, who had been in the position for three weeks, acknowledged the oversight. The Registered Dietitian, who often assisted on the tray line, was unaware of the resident's unmet preference as it had not been discussed in meetings or reported by staff.
Failure to Safely Assist Resident During Transfer
Penalty
Summary
The facility failed to safely assist a resident during a transfer, resulting in a deficiency related to accident hazards and supervision. Resident #1, who was severely cognitively impaired and required extensive assistance with transfers, was transferred by a single nurse aide without the use of a mechanical lift, as specified in the resident's care plan. The nurse aide, who was an agency staff member and unfamiliar with the resident, assumed the resident was a one-person assist due to a lack of proper orientation and education on the resident's care needs. Observations revealed that the nurse aide transferred the resident from the bed to a wheelchair without any visible incident, but without following the care guide that required a mechanical lift. Interviews with facility staff, including the unit manager, nurse, director of nursing, and administrator, confirmed that the nurse aide was not properly informed about the resident's transfer requirements. The staff acknowledged that the resident had a history of falls and should have been transferred using a mechanical lift, as documented in the care guide and care plan.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess residents for the ability to self-administer medications for two residents. Resident #2, who was cognitively intact, had physician orders for Gabapentin and Hydrocodone-Acetaminophen but no orders to self-medicate. An observation revealed that medications were left on Resident #2's overbed table, and the resident admitted to not taking them immediately. The Director of Nursing confirmed that no residents were allowed to self-medicate, and Nurse #1 admitted to leaving the medications, thinking the resident had taken them. The Administrator reiterated that residents were not allowed to self-administer medications without an assessment. Resident #3, also cognitively intact, was found with a bottle of antacid chewable tablets on her overbed table. Multiple observations confirmed the presence of the tablets, and the resident admitted to taking some. Nurse #2 and the Director of Nursing both confirmed that residents were not allowed to self-administer medications and that Resident #3 had not been assessed for this ability. The Administrator confirmed that the antacid tablets were removed and stored securely. Both incidents highlight the facility's failure to assess residents for self-administration of medications and to ensure that medications were not left at residents' bedsides. This lack of assessment and improper handling of medications led to residents having unauthorized access to their medications, which is against the facility's policy and procedures.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents who were dependent on staff for activities of daily living. Resident #4, who was admitted with diagnoses including hemiplegia and muscle weakness, was observed to have long, dirty fingernails despite being scheduled for regular showers. The resident's care plan indicated a need for maximal assistance with personal hygiene, yet staff interviews revealed inconsistencies in performing nail care. The resident's representative had previously raised concerns about the resident's nail hygiene, but the issue persisted. Observations confirmed that the resident had long, dirty fingernails with a brown substance underneath, and staff members admitted to not noticing or addressing the issue adequately. Resident #5, admitted with vascular dementia and requiring substantial assistance for personal hygiene, also had long, dirty fingernails. Despite being scheduled for regular showers, there was no documentation of nail care in the resident's records. Observations confirmed that the resident had long, dirty fingernails with a brown substance underneath. Staff interviews revealed that some nurse aides were uncomfortable with cutting nails and would report the issue to a nurse instead. However, there was no clear protocol or monitoring system in place to ensure that nail care was consistently performed. Interviews with the Staff Development Coordinator, Unit Manager, Director of Nursing, and Administrator highlighted a lack of clarity and consistency in the facility's nail care procedures. While staff were trained to perform nail care, there was no system in place to audit or monitor its completion. The Director of Nursing and Administrator were unaware of the specific deficiencies in nail care for Residents #4 and #5, indicating a gap in oversight and communication within the facility.
Inaccurate MDS Coding for PASRR and Restraints
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for several residents, leading to discrepancies in their Preadmission Screening and Resident Review (PASRR) levels and restraint usage. Resident #41, who had diagnoses including hemiplegia, hemiparesis, anxiety, and psychosis, was not coded as having a level II PASRR on his MDS despite a determination letter indicating otherwise. The MDS Coordinator, who started in October 2023, was unaware of this requirement, and both the Administrator and Director of Nursing (DON) confirmed the oversight was due to human error. Similarly, Resident #102, diagnosed with dementia, was not coded as having a level II PASRR on her MDS, despite a determination letter from May 2021. The MDS Coordinator attributed this to an oversight by the previous coordinator. Both the Administrator and DON were unaware of this discrepancy and acknowledged it as an error that needed correction. Resident #84, with diagnoses of dementia, schizophrenia, and anxiety, was also not correctly coded for a level II PASRR on the MDS, despite having a PASRR identification number in the medical record. The MDS Coordinator initially misunderstood the PASRR status, leading to the incorrect coding. Additionally, Resident #110 was incorrectly coded for the use of a limb restraint on the quarterly MDS assessment, despite no evidence of restraint use in the care plans or previous MDS assessments. The current MDS Coordinators confirmed that the resident did not use a limb restraint and attributed the error to a previous coordinator. The Administrator emphasized the expectation for accurate MDS assessments and the need for entries to be checked before final submission.
Improper Labeling and Storage of Insulin Pens
Penalty
Summary
The facility failed to properly label and store insulin pens in accordance with professional principles. During an observation of the Garden City medication cart, an opened Glargine insulin pen and an opened Novolin insulin pen were found without open dates. Additionally, an opened insulin pen with an open date of 12/08/2023 was found, which had passed its 28-day expiration date. Nurse #6 was unaware of the missing dates and the expired insulin pen, believing that the 3rd shift nursing staff were responsible for checking the medication carts for expired medications. Similarly, an observation of the Arboretum Cart revealed two unopened insulin pens stored in the medication cart instead of the refrigerator, and a Glargine insulin pen with an illegible open date. Nurse #7 did not realize the insulin pens lacked open dates, were not refrigerated, and had an illegible open date. The Director of Nursing confirmed that all insulin pens should be labeled with a 28-day expiration date when opened, stored in the refrigerator until use, and checked regularly by all nurses to ensure no expired medications are available for use.
Expired and Unlabeled Food Items Found in Nourishment Room
Penalty
Summary
The facility failed to remove expired food items and unlabeled personal items from a resident's nourishment room. During an observation and interview with a Nurse Aide (NA), an 8 oz. fat-free milk with an expired best-by date and three unlabeled lunch bags were found in the memory care unit nourishment room. The NA indicated that nursing staff stored their personal items in the nourishment room due to the break room being located on the other side of the facility. The NA also mentioned that nursing staff had been educated not to store personal items in the nourishment room and to discard expired items. The Dietary Manager (DM) confirmed that dietary aides check nourishment rooms daily but could not recall if they had been checked over the weekend. The Director of Nursing (DON) stated that nursing staff were educated not to store personal belongings in the nourishment rooms and were responsible for discarding expired items. The Administrator expected staff to check nourishment rooms daily and discard any expired or unlabeled items, and confirmed that it was inappropriate for nursing staff to store personal items in the nourishment room refrigerator.
Repeat Deficiencies in MDS Coding, Food Sanitation, and Infection Control
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions following multiple surveys, resulting in repeat deficiencies. Specifically, the facility failed to accurately code the Minimum Data Set (MDS) assessment for several residents, including those reviewed for Preadmission Screening and Resident Review (PASRR) and restraints. Additionally, the facility did not accurately code the MDS assessment related to tobacco use for residents reviewed for smoking. These inaccuracies were identified during the recertification and complaint investigation surveys. The facility also failed to maintain sanitary conditions in food storage areas, as expired and unlabeled food items were found in multiple nourishment rooms and the walk-in cooler. Furthermore, the facility did not ensure proper hand hygiene and infection control practices during wound care and incontinence care for several residents. Staff members were observed not following hand hygiene protocols, such as not sanitizing hands and changing gloves between tasks, which compromised infection control measures. These deficiencies were noted during both the focused infection control survey and the recertification and complaint investigation surveys.
Failure to Complete PASRR Level II for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II was completed for residents with mental health diagnoses upon admission and for residents with new mental health diagnoses. Specifically, three residents were affected: Resident #141, who was diagnosed with delusional disorder and severe dementia with psychotic disturbance upon admission; Resident #31, who was diagnosed with dementia with mood disturbance disorder after admission; and Resident #49, who was diagnosed with major depressive disorder after admission. In each case, the required PASRR Level II was not completed, despite the diagnoses indicating it was necessary. Interviews with the Social Worker (SW) and the Administrator revealed that the SW was responsible for completing PASRR assessments upon admission, changes in condition, or new diagnoses. The SW admitted that Resident #141's PASRR Level II was overlooked, and she was not made aware of the new diagnoses for Residents #31 and #49. The Administrator confirmed that PASRR Level II should have been completed in a timely manner for all three residents based on their mental health diagnoses, but this was not done, leading to the deficiency noted in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Charlotte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crown Haven Health And Rehabilitation | 3 mi | ★★★★★ | 0 | 0 |
| Rockwell Park Rehabilitation And Healthcare Center | 3.2 mi | — | 11 | 1 |
| Shamrock Nursing Center | 5.7 mi | ★★★★★ | 0 | 0 |
| Pruitthealth-town Center | 5.9 mi | ★★★★★ | 4 | 0 |
| Asbury Health And Rehabilitation Center | 5.9 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.