Deficiency Records for University Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for University Health and Rehabilitation 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-11 | 2024-02-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-11 | 2024-02-10 | 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 | 2024-01-11 | 2024-02-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-11 | 2024-02-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-11 | 2024-02-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-11 | 2024-02-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-11 | 2024-02-10 | 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 | 2024-01-09 | 2024-02-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-15 | 2022-12-15 | 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 | 2022-11-15 | 2022-12-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-15 | 2022-12-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-15 | 2022-12-15 | 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 | 2022-11-15 | 2022-12-15 | 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 | 2022-11-15 | 2022-12-15 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-11-15 | 2022-12-15 | 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 | 2022-11-15 | 2022-12-15 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-11-15 | 2022-12-15 | 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 | 2022-11-15 | 2022-12-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-15 | 2022-12-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-07 | 2022-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-07 | 2022-12-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-07 | 2022-12-15 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2020-10-23 | 2020-11-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-10-23 | 2020-11-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-10-23 | 2020-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-10-23 | 2020-11-22 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2020-10-23 | 2020-11-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-10-23 | 2020-11-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-23 | 2020-11-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-10-23 | 2020-11-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-10-23 | 2020-11-22 | 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 | 2020-10-23 | 2020-11-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-10-23 | 2020-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-23 | 2020-11-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-10-22 | 2020-11-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-10-22 | 2020-11-22 | N |
