UNIVERSITY VILLAGE RETIREMENT COMMUNITY

Nursing Home Inspector

8555 SOUTH LEWIS AVENUE
TULSA, OK 74137
Tulsa County
Phone: 918-299-2661
Provider Number: 375531
Last Inspection: 03/30/2017

About the Nursing Home

Number of Beds: 80
Number of Residents: 73
Beds Available: 7
Percent Occupancy: 91%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

8

Facility
25

County
26

OK
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

8

2017
18

2016
52

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

3/30/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure residents maintain acceptable nutritional status. Pattern : Minimal 4 4/26/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 4/26/2017
 

2/25/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 4/1/2016
 
Failed To: Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. Pattern : Minimal 4 4/1/2016
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 4/1/2016
 
Failed To: Give each resident enough fluids to keep them healthy and prevent dehydration. Pattern : Minimal 4 4/1/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 4/1/2016
 

1/8/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 2/16/2015
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 2/16/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 2/16/2015
 
Failed To: Maintain 15 months of resident assessments in the resident's active clinical record. Widespread : Potential 4 2/16/2015
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 2/16/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 2/16/2015
 
Failed To: 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. Pattern : Minimal 4 2/16/2015
 
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Pattern : Minimal 4 2/16/2015
 
Failed To: Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. Isolated : Minimal 3 2/16/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 2/16/2015
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 2/16/2015
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 2/16/2015
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern : Minimal 4 2/16/2015
 
Failed To: Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. Pattern : Minimal 4 2/16/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

6/10/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that residents are safe from serious medication errors. Pattern : Minimal 4 8/19/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg OK State Avg
Number of Residents 73 76.97 61.05
Registered Nurses 0.58 0.50 0.47
Licensed Practical / Vocational Nurses 0.95 0.95 0.83
Certified Nursing Assistants 3.09 2.71 2.47
Total Staff Hours 4.63 4.15 3.77

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% OK State Avg%
of high risk long-stay residents with pressure ulcers 3 7 7
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 89 91
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 98 94 95
of long-stay residents experiencing one or more falls with major injury 10 5 5
of long-stay residents who have depressive symptoms 12 5 5
of long-stay residents who lose too much weight 16 9 8
of long-stay residents who received an antianxiety or hypnotic medication 18 23 29
of long-stay residents who received an antipsychotic medication 8 14 19
of long-stay residents who self-report moderate to severe pain 13 8 9
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 13 20 15
of long-stay residents whose need for help with daily activities has increased 16 17 15
of long-stay residents with a catheter inserted and left in their bladder 3 2 2
of long-stay residents with a urinary tract infection 14 4 5
of low risk long-stay residents who lose control of their bowels or bladder 81 42 34
of short-stay residents assessed and appropriately given the pneumococcal vaccine 95 78 79
of short-stay residents who had an outpatient emergency department visit 12 12 16
of short-stay residents who made improvements in function 67 65 64
of short-stay residents who newly received an antipsychotic medication 0 2 2
of short-stay residents who self-report moderate to severe pain 26 17 20
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 91 74 74
of short-stay residents who were rehospitalized after a nursing home admission 24 23 23
of short-stay residents who were successfully discharged to the community 59 51 48
of short-stay residents with pressure ulcers that are new or worsened 1 1 1