A list of the most recent deficiencies for University Nursing and Rehab Ctr. 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? |
|---|---|---|---|---|
| Keep residents' personal and medical records private and confidential. | Health | 2023-12-09 | 2024-01-23 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-12-09 | 2024-01-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-09 | 2024-01-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-09 | 2024-01-23 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-12-09 | 2024-01-23 | 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 | 2023-12-09 | 2024-01-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-09 | 2024-01-23 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-12-09 | 2024-01-23 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-09 | 2024-01-23 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-12-09 | 2024-01-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-09 | 2024-01-23 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-12-09 | 2024-01-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-09 | 2024-01-23 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-12-09 | 2024-01-23 | Y |
| Install proper backup exit lighting. | Fire Safety | 2023-12-06 | 2024-01-23 | 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 | 2023-12-06 | 2024-01-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-12-06 | 2024-01-23 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2023-12-06 | 2024-01-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-12-06 | 2024-01-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-02 | 2023-06-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-23 | 2023-04-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-23 | 2023-04-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-23 | 2023-04-09 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-06-20 | 2022-08-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-06-20 | 2022-08-12 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-06-20 | 2022-08-12 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-06-20 | 2022-08-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-20 | 2022-08-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-20 | 2022-08-12 | 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 | 2022-06-20 | 2022-08-12 | N |
| 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 | 2022-06-20 | 2022-08-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-24 | 2022-04-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-24 | 2022-04-06 | 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 | 2022-02-24 | 2022-04-06 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-02-24 | 2022-04-06 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-24 | 2022-04-06 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-02-24 | 2022-04-06 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-02-07 | 2019-03-24 | 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 | 2019-02-07 | 2019-03-24 | 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 | 2019-02-07 | 2019-03-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-02-07 | 2019-03-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-02-05 | 2019-03-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-02-05 | 2019-03-24 | N |
