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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
Residents84
Percent Occupied69%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
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

November 3, 2016 - 5 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionProvide housekeeping and maintenance services.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
DFewPotential for HarmHealth InspectionEnsure each resident receives an accurate assessment by a qualified health professional.
DFewPotential for HarmHealth Inspection1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

June 3, 2016 - 10 months ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
DFewPotential for HarmComplaintProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmComplaintProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.

February 3, 2016 - 14 months ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$19,110 fine
DFewPotential for HarmComplaintMake sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
DFewPotential for HarmComplaintHave a program that investigates, controls and keeps infection from spreading.
DFewPotential for HarmComplaintEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
DFewPotential for HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .

April 16, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$8,938 fine
ESomePotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
DFewPotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .

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 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 HarmHealth InspectionGive residents a notice of rights, rules, services and charges.

September 24, 2014 - 3 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

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.

1hr 60min
2hr 20min
ReportedExpected
CNA
1hr 20min
40min
ReportedExpected
LPN
30min
1hr 5min
ReportedExpected
RN
3hr 50min
4hr 5min
ReportedExpected
Total Nursing

This facility also provides approximately 10min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

84.6%
90.8%
90.8%
90.8%
94.1%
Q4 2015Q1 2016Q2 2016Q3 2016GA
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
89.5%
86.7%
92.0%
92.8%
93.2%
Q4 2015Q1 2016Q2 2016Q3 2016GA
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
29.0%
30.6%
24.2%
30.0%
46.7%
Q4 2015Q1 2016Q2 2016Q3 2016GA
Percentage of low risk long-stay residents who lose control of their bowels or bladder
40.3%
44.9%
35.9%
46.8%
26.1%
Q4 2015Q1 2016Q2 2016Q3 2016GA
Percentage of long-stay residents who received an antianxiety or hypnotic medication
31.2%
24.4%
15.6%
25.6%
17.7%
Q4 2015Q1 2016Q2 2016Q3 2016GA
Percentage of long-stay residents whose ability to move independently worsened
33.3%
30.8%
32.4%
25.8%
19.7%
Q4 2015Q1 2016Q2 2016Q3 2016GA
Percentage of long-stay residents who received an antipsychotic medication
22.4%
23.9%
21.1%
21.4%
15.9%
Q4 2015Q1 2016Q2 2016Q3 2016GA
Percentage of long-stay residents whose need for help with daily activities has increased
6.9%
7.0%
3.9%
6.3%
7.6%
Q4 2015Q1 2016Q2 2016Q3 2016GA
Percentage of long-stay residents who self-report moderate to severe pain
5.5%
8.8%
7.2%
5.1%
7.3%
Q4 2015Q1 2016Q2 2016Q3 2016GA
Percentage of long-stay residents who lose too much weight
14.3%
16.3%
8.3%
12.5%
6.7%
Q4 2015Q1 2016Q2 2016Q3 2016GA
Percentage of high risk long-stay residents with pressure ulcers
3.0%
1.4%
1.3%
0.0%
6.0%
Q4 2015Q1 2016Q2 2016Q3 2016GA
Percentage of long-stay residents who have depressive symptoms
4.1%
6.2%
3.6%
3.8%
4.7%
Q4 2015Q1 2016Q2 2016Q3 2016GA
Percentage of long-stay residents with a urinary tract infection
2.6%
3.6%
3.4%
3.6%
3.4%
Q4 2015Q1 2016Q2 2016Q3 2016GA
Percentage of long-stay residents experiencing one or more falls with major injury
3.9%
3.7%
3.4%
7.6%
2.1%
Q4 2015Q1 2016Q2 2016Q3 2016GA
Percentage of long-stay residents with a catheter inserted and left in their bladder
2.6%
2.4%
3.4%
3.6%
0.5%
Q4 2015Q1 2016Q2 2016Q3 2016GA
Percentage of long-stay residents who were physically restrained

Quality Measures for Short Stay Residents

42.6%
44.3%
41.7%
66.0%
80.3%
Q4 2015Q1 2016Q2 2016Q3 2016GA
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
62.0%
46.4%
46.4%
46.4%
78.4%
Q4 2015Q1 2016Q2 2016Q3 2016GA
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
71.5%
69.0%
-
-
61.1%
Q4 2015Q1 2016Q2 2016Q3 2016GA
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who made improvements in function
-
-
-
-
15.6%
Q4 2015Q1 2016Q2 2016Q3 2016GA
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who self-report moderate to severe pain
3.7%
8.3%
13.0%
5.0%
2.8%
Q4 2015Q1 2016Q2 2016Q3 2016GA
Percentage of short-stay residents who newly received an antipsychotic medication
1.5%
0.0%
1.5%
1.9%
1.2%
Q4 2015Q1 2016Q2 2016Q3 2016GA
Percentage of short-stay residents with pressure ulcers that are new or worsened