Deficiency Records for University Heights Rehab and Care Community
Updated as of March 01, 2024
A list of the most recent deficiencies for University Heights Rehab and Care Community. 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 | 2023-07-19 | 2023-07-19 | Y |
Respond appropriately to all alleged violations. | Health | 2023-07-19 | 2023-07-19 | Y |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-10-26 | 2022-12-02 | N |
Provide properly protected cooking facilities. | Fire Safety | 2022-10-26 | 2022-11-28 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-26 | 2022-11-28 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-26 | 2022-11-28 | N |
Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-26 | 2022-11-02 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-29 | 2022-09-30 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-29 | 2022-09-30 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-29 | 2022-09-30 | N |
Provide activities to meet all resident's needs. | Health | 2022-09-29 | 2022-09-30 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-29 | 2022-09-30 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-29 | 2022-09-30 | 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 | 2022-09-29 | 2022-09-30 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-29 | 2022-09-30 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-29 | 2022-09-30 | 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 | 2022-09-29 | 2022-09-30 | 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 | 2022-09-29 | 2022-09-30 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-29 | 2022-09-30 | N |
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-09-29 | 2022-09-30 | N |
Provide and implement an infection prevention and control program. | Health | 2022-09-29 | 2022-09-30 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-14 | 2021-07-23 | N |
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-07-14 | 2021-07-19 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-14 | 2021-07-15 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-22 | 2021-06-23 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2021-06-22 | 2021-06-23 | N |
Provide and implement an infection prevention and control program. | Health | 2021-06-22 | 2021-06-23 | N |
Ensure that residents are free from significant medication errors. | Health | 2021-06-22 | 2021-06-22 | Y |
Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-17 | 2019-07-24 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-17 | 2019-07-10 | N |
Provide properly protected cooking facilities. | Fire Safety | 2019-06-17 | 2019-07-03 | N |
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-06-17 | 2019-07-03 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-21 | 2019-06-28 | N |
Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-05-21 | 2019-06-21 | N |
Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-05-21 | 2019-06-21 | 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 | 2019-05-21 | 2019-06-21 | N |
Provide activities to meet all resident's needs. | Health | 2019-05-21 | 2019-06-21 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-21 | 2019-06-21 | 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 | 2019-05-21 | 2019-06-21 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-21 | 2019-06-21 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-21 | 2019-06-21 | N |
Ensure that residents are free from significant medication errors. | Health | 2019-05-21 | 2019-06-21 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-05-21 | 2019-06-21 | N |
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-05-21 | 2019-06-21 | N |
Provide and implement an infection prevention and control program. | Health | 2019-05-21 | 2019-06-21 | N |