Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Center during CMS and state inspections, most recent first.
A resident receiving IV antibiotic therapy for osteomyelitis was at risk due to improper IV medication administration by an LVN. The LVN failed to remove air bubbles from the IV tubing and did not flush the PICC line before connecting the medication, which could have led to an air embolism. The facility lacked detailed training records and policies for IV administration, contributing to the deficiency.
A facility failed to ensure nurses demonstrated competency in IV therapy, leading to a deficiency when an LVN did not remove air bubbles from IV tubing or flush a PICC line before administering medication to a resident. The facility lacked a system to ensure IV therapy competency, and the LVN had not received proper certification or training.
The facility failed to provide adequate pharmaceutical services, including an LVN nearly crushing enteric-coated aspirin for a resident, and medication carts containing discontinued and expired medications. The DON confirmed that home medications should not be in carts to prevent errors.
The facility failed to store medications securely, as LVN A and MA F left medication carts unlocked and unattended in the hallway. This was observed in three out of four medication carts reviewed. Interviews confirmed that the carts should have been locked to prevent unauthorized access, as per facility policy.
The facility failed to maintain proper infection control practices, as observed in three separate incidents involving staff not adhering to hand hygiene and PPE protocols. An RN did not sanitize hands after glove removal during a blood sugar check, an LVN placed IV medication on unclean surfaces and did not don a gown in a precaution room, and another RN failed to sanitize hands before administering a subcutaneous injection. These actions were contrary to the facility's infection control policies.
A resident with major depressive disorder, hypertension, and dementia was unable to reach her call light, which was tied up and placed out of reach. This deficiency was confirmed by multiple staff members, including an IP, LVN, CNA, DON, and CM, who acknowledged the importance of the call light being accessible. The facility's policy requires that residents have a means to call for assistance, but this was not adhered to, leading to potential risks for the resident.
A facility failed to transmit a discharge MDS assessment to CMS within the required timeframe for a resident with dementia and a history of falls. The oversight occurred during a transition between electronic medical record systems, which did not flag the issue. The MDS assessment was eventually transmitted after the deadline.
A resident with a Foley catheter did not receive appropriate care, as a CNA placed the Foley bag at the same level as the bladder, risking backflow and infection. The CNA also failed to perform proper hand hygiene and did not clean the catheter insertion site correctly. These actions contradict the facility's care plan and infection control policies, potentially compromising the resident's health.
Two residents in a long-term care facility reported incidents of abuse that were not appropriately addressed or reported to the state, despite the facility's policy requiring such actions. One resident alleged inappropriate touching by a CNA, while another reported being roughly handled, resulting in bruises. The facility's staff were either unaware or did not recall the incidents, and no documentation was found in the facility's reporting system.
Two residents in the facility reported incidents of alleged abuse that were not reported to the state as required by law. One resident alleged inappropriate touching by a CNA, while another reported being grabbed and shoved into bed, resulting in bruises. Despite internal investigations, the facility failed to document or report these incidents to the state, as required by their policy.
Two residents in a facility reported allegations of abuse that were not thoroughly investigated or reported to the state as required. One resident alleged inappropriate touching by a CNA, while another reported being grabbed and shoved into bed, resulting in bruises. Despite the facility's policy requiring immediate reporting, staff interviews revealed a lack of awareness and documentation regarding these incidents.
The facility failed to provide timely pharmaceutical services for two residents, resulting in deficiencies in medication administration. One resident did not receive Procrit due to a delay in preauthorization for the high-cost medication, while another did not receive Paxlovid within the critical window for COVID-19 treatment. Both incidents were due to a lack of timely escalation and communication regarding medication procurement.
Deficiency in Safe IV Fluid Administration
Penalty
Summary
The facility failed to ensure the safe administration of intravenous (IV) fluids for a resident, leading to a deficiency identified by surveyors. The incident involved a Licensed Vocational Nurse (LVN) who did not follow proper procedures while administering IV medication to a resident. The resident, a male with a history of diabetes mellitus, hypertension, and heart failure, was receiving IV antibiotic therapy for osteomyelitis of the right toe. During the administration of IV meropenem, the LVN did not remove air bubbles from the IV tubing and failed to flush the Peripherally Inserted Central Catheter (PICC) line before connecting the medication, which could have resulted in an air embolism. The deficiency was observed when the LVN was about to connect the IV tubing with visible air bubbles to the resident's port. The surveyor intervened, prompting the LVN to prime the tubing and remove the bubbles. However, the LVN again failed to remove air from the flush syringe before attempting to flush the resident's port, requiring further intervention by the surveyor. Interviews with the LVN revealed a lack of awareness regarding the presence of air bubbles and the potential risk of air embolism, despite having received training in IV medication administration. Further investigation revealed that the facility did not have a record of IV administration training for its nurses from 2021 to the present. The Director of Nursing (DON) acknowledged that the LVN should have ensured the removal of air from the tubing and flushed the port to maintain patency and prevent complications. The facility's policy on IV medication administration was found to be lacking in detail, contributing to the improper procedure followed by the LVN.
Deficiency in IV Therapy Competency
Penalty
Summary
The facility failed to ensure that licensed nurses demonstrated competency in intravenous (IV) therapy techniques, which was necessary to care for residents' needs. This deficiency was observed in the case of a resident who required IV antibiotic therapy for osteomyelitis of the right toe. During an observation, a Licensed Vocational Nurse (LVN) was found to have not removed air bubbles from the IV tubing and did not flush the Peripherally Inserted Central Catheter (PICC) line port before administering IV medication. The LVN acknowledged the oversight and admitted that administering the medication with air bubbles could have caused an air embolism. Interviews with the Director of Nursing (DON) and the LVN revealed that the facility lacked a system to ensure the competency of nurses in IV therapy techniques. The DON stated that the LVN should have ensured all air was out of the tubing and flushed the port before administering the medication. The facility's contract pharmacy was supposed to provide IV training, but there was no record of such training from 2021 to the present. The LVN had not received an IV administration certificate, and the DON was unsure if it was a requirement. The facility's policy on IV medication administration was found to be inadequate, as it did not include a detailed step-by-step process for administering IV medications. The Texas Board of Nursing practice guidelines require LVNs to complete a validation course in IV therapy before engaging in such procedures. The facility's failure to ensure proper training and competency in IV therapy techniques placed residents at risk for serious harm, injury, and adverse effects from improper IV therapy techniques.
Pharmaceutical Service Deficiencies in Medication Administration and Storage
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by several deficiencies observed during the survey. One significant issue involved a Licensed Vocational Nurse (LVN) who was about to crush enteric-coated aspirin for a resident with a history of stroke, traumatic brain dysfunction, and traumatic spinal dysfunction. Crushing the enteric-coated aspirin would have compromised its delayed-release properties, potentially affecting the resident's treatment for deep vein thrombosis prophylaxis. The LVN acknowledged the error when stopped by the surveyor and admitted that the medication should not be crushed to ensure proper dosage and timing. Additionally, the survey revealed that the medication cart at station 1A contained discontinued medications for three residents. These medications were brought from home and were not supposed to be used by the facility. The Registered Nurse (RN) responsible for the cart stated that home medications should be stored in a zip-lock bag in the medication room to prevent errors. The Director of Nursing (DON) confirmed that home medications should not be kept in the cart to avoid conflicts with facility-prescribed doses. Further deficiencies were noted at station 2B, where two opened eye drop bottles had expired, and a discontinued medication was found in the cart. The LVN explained that discontinued medications should be removed immediately to prevent errors, and expired medications could harm residents if administered. The DON reiterated that expired medications would not be effective and should be disposed of properly. The facility's policies on medication storage and administration were not adhered to, leading to these deficiencies.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles, as observed in three out of four medication carts reviewed. LVN A left the medication carts at stations 2A and 2B unlocked in the hallway while administering medication to residents in their rooms. During interviews, LVN A admitted to forgetting to lock the carts, acknowledging the potential safety issue as residents could access the medications. Similarly, MA F left the station 1A medication cart unlocked and unattended in the hallway while administering medication to a resident, and also left two medication containers on top of the cart. Interviews with MA F and the Director of Nursing (DON) confirmed that the medication carts should have been locked when not in use to prevent unauthorized access. The facility's policy on medication labeling and storage mandates that all compartments containing medications must be locked when not in use, and carts should not be left unattended if open. The failure to adhere to these protocols posed a risk of medication errors and potential harm to residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to proper infection control procedures. RN A did not sanitize her hands after removing gloves that had blood spots during a blood sugar check for a resident, which was acknowledged as an infection control issue by both RN A and the Director of Nursing (DON). This oversight occurred despite the facility's policy requiring hand hygiene after glove removal. LVN A also failed to follow proper infection control procedures during the administration of IV medication to another resident. LVN A placed medication and tubing on an unclean surface and did not don a gown in an enhanced barrier precautions room. Additionally, LVN A touched his uniform pockets with gloved hands and continued the procedure without changing gloves, which he admitted could lead to cross-contamination. The DON confirmed that LVN A should have used a clean field and donned appropriate PPE. Another incident involved RN A not sanitizing her hands before donning gloves to administer a subcutaneous injection to a resident. This was recognized as cross-contamination by RN A, who admitted to forgetting the hand hygiene step. The DON reiterated the importance of hand hygiene upon entering a resident's room. These failures in infection control practices were observed despite the facility's policies and in-service training on infection control, PPE, and hand hygiene.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #7, had access to a call light within reach, which is necessary for requesting assistance. During an observation, it was noted that the call light was tied up and placed close to the wall, out of the resident's reach. Resident #7, who has a history of major depressive disorder, hypertension, and dementia, and requires partial to moderate assistance with activities of daily living, was unable to reach the call light when she needed help. This situation was confirmed by multiple staff members, including an Infection Preventionist (IP), a Licensed Vocational Nurse (LVN), a Certified Nursing Assistant (CNA), the Director of Nursing (DON), and the Clinical Manager (CM), all of whom acknowledged that the call light should have been within the resident's reach. The staff interviews revealed that the call light was essential for Resident #7 to call for assistance, and its inaccessibility could lead to delayed care or potential falls if the resident attempted to get up without help. The facility's policy on the call system mandates that each resident should have a means to call staff directly for assistance from their bed, toileting, bathing facilities, and the floor. Despite this policy, the call light was not positioned correctly, and the staff responsible for ensuring it was within reach did not fulfill their duties, leading to the deficiency noted in the report.
Failure to Timely Transmit MDS Assessment
Penalty
Summary
The facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS System within 14 days after completing a resident's assessment. Specifically, the facility did not complete and transmit a discharge MDS assessment for one resident, who was admitted with diagnoses including a fall and dementia, and later discharged to an assisted living facility. The MDS assessment for this resident was marked as completed but was not accepted in transmission to CMS until after the required timeframe. Interviews with the MDS Coordinator/RN and the Director of Nursing (DON) revealed that the missed MDS assessment was due to a transition between electronic medical record systems, which failed to flag the issue. The MDS Coordinator acknowledged the oversight and explained that the facility was in the process of implementing a new system to prevent such errors. The Administrator confirmed that the missed MDS assessment was eventually transmitted to CMS, and the facility was addressing the issue to avoid future occurrences.
Inadequate Foley Catheter Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate care for a resident with a Foley catheter, leading to potential risks of urinary tract infections. During an observation, it was noted that a CNA placed the Foley bag on the bed at the same level as the resident's bladder, which could cause urine to flow back into the bladder. This action contradicts the care plan intervention that requires the tubing and bag to be kept below the bladder to ensure proper drainage through gravity. Additionally, the CNA did not perform proper hand hygiene during the Foley care process. After wiping the resident's buttocks, the CNA opened a new packet of wipes with the same gloves used for cleaning, which could lead to cross-contamination. The CNA also failed to separate the resident's labia and clean the Foley catheter insertion site, which is necessary to prevent infection. The CNA admitted to these oversights during an interview, acknowledging the risk of infection due to improper cleaning and handling. The Director of Nursing confirmed that the Foley bag should always be below the bladder to prevent backflow and potential infection. The facility's policies on hand hygiene and perineal care emphasize the importance of proper procedures to prevent cross-contamination and infection. The failure to adhere to these protocols during the resident's care highlights deficiencies in the facility's practices, potentially compromising the resident's health.
Failure to Report and Address Allegations of Abuse
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse and neglect of residents, as well as to ensure the reporting of crimes occurring in federally-funded long-term care facilities. This deficiency was identified in the cases of two residents who reported incidents of abuse that were not appropriately addressed or reported to the relevant authorities. The facility's policy requires all employees and contractors to report suspected abuse, neglect, or exploitation to the Texas Health and Human Services Department of Aging and Disability Services, but this was not followed in these instances. Resident #24, who had a history of bipolar disorder and was dependent on staff for toileting hygiene, alleged that a CNA touched her groin area without permission. Despite the resident's intact cognition and clear expression of discomfort, the incident was not reported to the state as required. The facility's staff, including the Quality Patient Safety Specialist and the interim Administrator, were either unaware of the incident or did not recall it, and no documentation was found in the facility's reporting system. Resident #45, who required extensive assistance with activities of daily living, reported that someone grabbed her hands and shoved her in bed, resulting in bruises. The incident was communicated to the facility's staff, including the former DON and the former Administrator, but was not reported to the state. The facility's staff had varying recollections of the incident, with some attributing the bruises to the resident's use of blood thinners. Despite the facility's policy to report such allegations within a two-hour timeframe, no report was made, and the incident was not documented in the facility's records.
Failure to Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the State survey Agency as required by State law. Resident #24 alleged that a CNA touched her groin area without permission on 5/11/24. Despite the resident expressing discomfort and a lack of safety with the night shift staff, the incident was not reported to the state. The facility's internal investigation did not result in any findings, and there was no documentation of the incident in the TULIP portal. Interviews with various staff members, including the interim Administrator and Quality Patient Safety Specialist, revealed a lack of awareness or documentation regarding the incident. Resident #45 reported that on 5/15/24, someone grabbed her hands and shoved her into bed, resulting in bruises on her arms. The incident was communicated to the DON and the former Administrator, but it was not reported to the state. The resident's family was informed of the incident, and the former DON assessed the resident, noting discoloration on her arms. However, the facility did not document the incident in the TULIP portal, and interviews with staff members, including the former Administrator and VPO, indicated a lack of clarity and documentation regarding the incident. The facility's policy requires all employees and contractors to report suspected abuse, neglect, or exploitation to the Texas Health and Human Services Department. However, in both cases, the facility failed to adhere to this policy, resulting in a lack of timely reporting to the state. The failure to report these incidents could place residents at risk for abuse and/or neglect, as the facility did not follow established procedures for reporting and investigating allegations of abuse.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse were thoroughly investigated and reported to the State Survey Agency within the required timeframe for two residents. Resident #24 alleged inappropriate touching by a CNA during care, which was not thoroughly investigated or reported. The resident, who had intact cognition and was dependent on assistance for toileting hygiene, expressed discomfort with the care provided. Despite the resident's clear expression of feeling unsafe and the subsequent transfer for suicidal ideation, the facility did not document or report the incident as required. Resident #45 reported being grabbed and shoved into bed by a staff member, resulting in bruises on her arms. The resident, who also had intact cognition, required extensive assistance with activities of daily living. Despite the resident's report and visible bruising, the facility did not conduct a thorough investigation or report the incident to the state. Interviews with staff revealed a lack of awareness and documentation regarding the incident, and the facility's internal processes failed to escalate the report appropriately. The facility's policy requires immediate reporting of suspected abuse to the appropriate state agencies, but this was not adhered to in these cases. Interviews with various staff members, including the interim Administrator and Quality Patient Safety Specialist, indicated a lack of knowledge about the incidents and an absence of documentation. The failure to investigate and report these allegations of abuse could place residents at risk, as their concerns were not addressed in accordance with regulatory requirements.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents, resulting in deficiencies in medication administration. For one resident, the facility did not ensure the availability of Procrit (Epoetin alfa) as ordered by the physician. The medication was delayed due to its high cost, and the necessary preauthorization form was not promptly completed. The nurse involved did not escalate the issue to the next level of management, which contributed to the delay in medication delivery. Despite the delay, the resident did not miss any doses. Another resident did not receive Paxlovid as ordered for COVID-19 treatment. The medication was not delivered within the critical window due to its high cost and the need for preauthorization. The facility failed to escalate the issue in a timely manner, resulting in the medication not being administered before it was discontinued. The resident's condition could have been negatively impacted due to the delay in receiving the medication. Both incidents highlight a breakdown in communication and escalation processes within the facility, particularly concerning high-cost medications requiring preauthorization. The facility's failure to ensure timely medication delivery and administration as per physician orders led to these deficiencies.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Houston Transitional Care | 0.7 mi | ★★★★★ | 1 | 0 |
| Clarewood House Extended Care Center | 1.3 mi | ★★★★★ | 2 | 0 |
| Seven Acres Jewish Senior Care Services | 1.4 mi | ★★★★★ | 2 | 0 |
| Sharpville Residence And Rehabilitation Center | 1.5 mi | ★★★★★ | 1 | 0 |
| The Lev At Town Park | 2.2 mi | ★★★★★ | 2 | 2 |
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