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University Nursing & Rehab Ctr

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About University Nursing & Rehab Ctr

General Information

Legal Business NameUniverse Cypress LLC
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareJanuary 1, 1990 (27 years)
Capacity122
Residents86
Percent Occupied70%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsBoth
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for University Nursing & Rehab Ctr

University Nursing & Rehab Ctr
was reviewed by Medicare to have a rating of 1 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Georgia Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

April 16, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$8,938 fine
ESomePotential for HarmFire Safety InspectionA written emergency evacuation plan.
ESomePotential for HarmFire Safety InspectionA fire alarm system that can be heard throughout the facility.
ESomePotential for HarmFire Safety InspectionAn approved automatic sprinkler system connected to the fire alarm system.
ESomePotential for HarmFire Safety InspectionRestrictions on the use of portable space heaters.
ESomePotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.
ESomePotential for HarmFire Safety InspectionSpecial areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system.
ESomePotential for HarmFire Safety InspectionCorridors that are separated from use areas by walls constructed to limit the passage of smoke.
ESomePotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
DFewPotential for HarmFire Safety InspectionNo-smoking signs where oxygen is used.
DFewPotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.
DFewPotential for HarmFire Safety InspectionOther fire safety features required by fire safety codes.
DFewPotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmFire Safety InspectionRecord of quarterly fire drills for each shift under varying conditions.
DFewPotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmFire Safety InspectionProperly installed hallway dispensers for alcohol-based hand rub.

October 2, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
CManyPotential for Minimal HarmHealth InspectionKeep all essential equipment working safely.
DFewPotential for HarmHealth InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmHealth InspectionEnsure services provided by the nursing facility meet professional standards of quality.
DFewPotential for HarmHealth InspectionGive residents a notice of rights, rules, services and charges.
DFewPotential for HarmHealth InspectionEnsure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care.
DFewPotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.

September 24, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintKeep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
DFewPotential for HarmComplaintAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.

May 9, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$170,235 fine
JFewImmediate JeopardyComplaintGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
JFewImmediate JeopardyComplaintSet up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
JFewImmediate JeopardyComplaintMake sure that the facility is administered in an acceptable way that maintains the well-being of each resident .
JFewImmediate JeopardyComplaintProvide care by qualified persons according to each resident's written plan of care.
JFewImmediate JeopardyComplaintProtect each resident from mistreatment, neglect and misappropriation of personal property.
JFewImmediate JeopardyComplaintEnsure services provided by the nursing facility meet professional standards of quality.
JFewImmediate JeopardyComplaintEnsure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.

February 5, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$114,953 fine
JFewImmediate JeopardyComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
JFewImmediate JeopardyComplaintEnsure services provided by the nursing facility meet professional standards of quality.
JFewImmediate JeopardyComplaintAllow residents the right to participate in the planning or revision of care and treatment.
JFewImmediate JeopardyComplaintProtect each resident from mistreatment, neglect and misappropriation of personal property.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of University Nursing & Rehab Ctr require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 15min
2hr 15min
ReportedExpected
CNA
1hr 15min
45min
ReportedExpected
LPN
30min
1hr 10min
ReportedExpected
RN
4hr
4hr 5min
ReportedExpected
Total Nursing

This facility also provides approximately 25min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

84.3%
84.6%
84.6%
94.7%
Q1 2015Q2 2015Q3 2015GA
Assessed and Appropriately Given the Seasonal Influenza Vaccine
96.4%
96.2%
90.3%
93.9%
Q1 2015Q2 2015Q3 2015GA
Assessed and Appropriately Given the Pneumococcal Vaccine
-
-
-
47.5%
Q1 2015Q2 2015Q3 2015GA
* The data for this facility for some quarters is unavailable.
Low Risk Residents Who Lose Control of Their Bowel or Bladder
20.3%
25.0%
25.0%
19.9%
Q1 2015Q2 2015Q3 2015GA
Received an Antipsychotic Medication
23.1%
20.3%
41.9%
16.0%
Q1 2015Q2 2015Q3 2015GA
Need for Help with ADLs has Increased
15.1%
12.0%
7.7%
8.3%
Q1 2015Q2 2015Q3 2015GA
Self Report Moderate to Severe Pain
9.8%
6.4%
9.9%
8.1%
Q1 2015Q2 2015Q3 2015GA
Lose Too Much Weight
13.5%
17.8%
11.9%
6.9%
Q1 2015Q2 2015Q3 2015GA
High Risk Residents With Pressure Ulcers
0.0%
2.9%
0.0%
6.8%
Q1 2015Q2 2015Q3 2015GA
Have Depressive Symptoms
9.8%
9.0%
7.0%
5.3%
Q1 2015Q2 2015Q3 2015GA
With a Urinary Tract Infection
2.4%
2.6%
2.8%
3.3%
Q1 2015Q2 2015Q3 2015GA
Experiencing One or More Falls with Major Injury
2.0%
3.2%
4.7%
2.4%
Q1 2015Q2 2015Q3 2015GA
With a Catheter Inserted and Left in Their Bladder
2.4%
3.8%
0.0%
0.8%
Q1 2015Q2 2015Q3 2015GA
Were Physically Restrained

Quality Measures for Short Stay Residents

61.1%
58.0%
31.4%
81.4%
Q1 2015Q2 2015Q3 2015GA
Assessed and Appropriately Given the Pneumococcal Vaccine
68.8%
62.0%
62.0%
80.9%
Q1 2015Q2 2015Q3 2015GA
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
-
-
20.0%
15.8%
Q1 2015Q2 2015Q3 2015GA
* The data for this facility for some quarters is unavailable.
Self Report Moderate to Severe Pain
7.0%
2.6%
5.9%
2.9%
Q1 2015Q2 2015Q3 2015GA
Newly Received an Antipsychotic Medication
0.7%
2.3%
2.5%
1.2%
Q1 2015Q2 2015Q3 2015GA
With Pressure Ulcers That Are New or Worsened