Deficiency Records for University Park Healthcare Center
Updated as of May 01, 2024
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Deficiency Records for University Park Healthcare Center
A list of the most recent deficiencies for University Park Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for University Park Healthcare 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-28 | 2024-04-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-28 | 2024-04-19 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-01-25 | 2024-03-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-02-23 | 2024-03-18 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-01-25 | 2024-02-23 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-01-25 | 2024-02-23 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-25 | 2024-02-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-25 | 2024-02-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-25 | 2024-02-23 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2024-01-25 | 2024-02-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-25 | 2024-02-23 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-01-25 | 2024-02-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-25 | 2024-02-23 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-25 | 2024-02-23 | 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 | 2024-01-25 | 2024-02-23 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-01-25 | 2024-02-23 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-25 | 2024-02-23 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-25 | 2024-02-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-25 | 2024-02-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-25 | 2024-02-23 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-29 | 2024-02-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-01-29 | 2024-02-18 | 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 | 2024-01-29 | 2024-02-18 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-01-29 | 2024-02-18 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2024-01-29 | 2024-02-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-29 | 2024-02-18 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-01-29 | 2024-02-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-29 | 2024-02-18 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-01-29 | 2024-02-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-29 | 2024-02-18 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-01-29 | 2024-02-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-29 | 2024-02-18 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2024-01-29 | 2024-02-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-29 | 2024-02-18 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-01-29 | 2024-02-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-29 | 2024-02-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-29 | 2024-02-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-29 | 2024-02-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-29 | 2024-02-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-29 | 2024-02-18 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-01-23 | 2024-02-09 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-12-19 | 2024-01-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-01 | 2023-11-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-01 | 2023-11-13 | Y |
| 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 | 2023-11-01 | 2023-11-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-31 | 2023-09-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-31 | 2023-09-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-21 | 2023-08-21 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-06-28 | 2023-07-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-28 | 2023-07-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-18 | 2023-06-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-22 | 2023-04-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-22 | 2023-04-17 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-03-03 | 2023-03-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-04 | 2023-03-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-26 | 2023-02-14 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-01-26 | 2023-02-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-26 | 2023-02-14 | Y |
| 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 | 2022-12-14 | 2022-12-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-08 | 2022-11-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-08 | 2022-11-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-08 | 2022-11-15 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-11-08 | 2022-11-15 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-11-07 | 2022-11-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-19 | 2022-09-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-19 | 2022-09-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-25 | 2022-08-31 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-07-25 | 2022-08-31 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-25 | 2022-08-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-08 | 2022-08-31 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-06-08 | 2022-08-31 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-08-09 | 2022-08-27 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-06-29 | 2022-07-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-14 | 2022-05-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-17 | 2022-03-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-04 | 2022-03-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-04 | 2022-03-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-24 | 2022-03-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-24 | 2022-03-08 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-01-31 | 2022-02-17 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-01-11 | 2022-01-26 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2021-12-24 | 2022-01-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-29 | 2021-11-12 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-10-29 | 2021-11-12 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-10-29 | 2021-11-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-29 | 2021-11-12 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-10-26 | 2021-11-08 | Y |
| Post nurse staffing information every day. | Health | 2021-10-26 | 2021-11-08 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-10-26 | 2021-11-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-26 | 2021-11-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-18 | 2021-10-28 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-04-08 | 2021-05-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-04-08 | 2021-05-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-08 | 2021-05-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-08 | 2021-05-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-08 | 2021-05-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-04-08 | 2021-05-07 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2021-04-08 | 2021-05-07 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-04-09 | 2021-05-06 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-04-09 | 2021-05-06 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-04-09 | 2021-05-06 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-04-09 | 2021-05-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-09 | 2021-05-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-09 | 2021-05-06 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2020-02-10 | 2020-03-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-02-10 | 2020-03-20 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-02-10 | 2020-03-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-10 | 2020-03-20 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-02-10 | 2020-03-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-10 | 2020-03-20 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-02-10 | 2020-03-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-02-10 | 2020-03-20 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-02-10 | 2020-03-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-10 | 2020-03-20 | 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 | 2020-02-10 | 2020-03-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-10 | 2020-03-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-02-10 | 2020-03-20 | 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 | 2020-02-10 | 2020-03-20 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2020-02-10 | 2020-03-20 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2020-02-10 | 2020-03-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-10 | 2020-03-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-02-10 | 2020-03-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-05 | 2020-02-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-05 | 2020-02-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-05 | 2020-02-27 | 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 | 2022-02-23 | Not Fixed | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-02-23 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-23 | Not Fixed | N |
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