A list of the most recent deficiencies for University Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-04 | 2023-12-19 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-12-04 | 2023-12-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-25 | 2023-11-24 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-25 | 2023-11-24 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-09-11 | 2023-09-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-10 | 2023-08-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-22 | 2023-07-19 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-21 | 2023-03-20 | N |
| Use approved construction type or materials. | Fire Safety | 2023-02-21 | 2023-03-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-21 | 2023-03-20 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-02-21 | 2023-03-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-21 | 2023-03-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-02-21 | 2023-03-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-21 | 2023-03-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-21 | 2023-03-20 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-02-21 | 2023-03-20 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-02-21 | 2023-03-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-21 | 2023-03-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-17 | 2023-03-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-17 | 2023-03-16 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-02-17 | 2023-03-16 | N |
| Provide activities to meet all resident's needs. | Health | 2023-02-17 | 2023-03-16 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-02-17 | 2023-03-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-17 | 2023-03-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-17 | 2023-03-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-02-17 | 2023-03-16 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-17 | 2023-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-17 | 2023-03-16 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2023-02-17 | 2023-03-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-17 | 2023-03-16 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-02-17 | 2023-03-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-17 | 2023-03-16 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-02-17 | 2023-03-16 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-02-17 | 2023-03-16 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-17 | 2023-03-16 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-02-17 | 2023-03-16 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-02-22 | 2023-03-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-06 | 2023-03-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-16 | 2022-01-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-07 | 2021-05-04 | Y |
| Provide primary/alternate means for communication. | Fire Safety | 2019-09-19 | 2019-10-08 | N |
| Use approved construction type or materials. | Fire Safety | 2019-09-19 | 2019-10-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-09-19 | 2019-10-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-19 | 2019-10-08 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2019-09-19 | 2019-10-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-19 | 2019-10-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-19 | 2019-10-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-23 | 2019-09-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-23 | 2019-09-12 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-08-23 | 2019-09-12 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-10-05 | 2018-10-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-10-05 | 2018-10-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-05 | 2018-10-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-10-05 | 2018-10-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-05 | 2018-10-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-08-09 | 2018-09-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-08-09 | 2018-09-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-08-09 | 2018-09-14 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-08-09 | 2018-09-14 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-08-09 | Not Fixed | N |
