Deficiency Records for University Hills Health and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for University Hills Health and Rehabilitation. 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? |
|---|---|---|---|---|
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-06-15 | 2023-07-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-15 | 2023-07-28 | 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 | 2023-06-15 | 2023-07-28 | 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 | 2023-06-14 | 2023-07-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-14 | 2023-07-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-14 | 2023-07-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-14 | 2023-07-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-06 | 2023-05-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-06 | 2023-05-06 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-04-06 | 2023-05-06 | Y |
| 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 | 2022-12-22 | 2023-03-09 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-12-22 | 2023-03-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-22 | 2023-01-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-22 | 2023-01-26 | Y |
| 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 | 2022-08-16 | 2022-09-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-16 | 2022-09-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-03 | 2022-03-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-21 | 2021-08-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-01-14 | 2021-02-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-01-14 | 2021-02-14 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-01-14 | 2021-02-14 | N |
| Dispose of garbage and refuse properly. | Health | 2021-01-14 | 2021-02-14 | N |
