Deficiency Records for University Place Health Center and Assisted Living
Updated as of March 01, 2024
A list of the most recent deficiencies for University Place Health Center and Assisted Living. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-01 | 2024-01-30 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-12-01 | 2024-01-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-01 | 2024-01-30 | 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 | 2023-12-01 | 2024-01-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-01 | 2024-01-30 | N |
| Post nurse staffing information every day. | Health | 2023-12-01 | 2024-01-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-12-01 | 2024-01-30 | 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 | 2023-12-01 | 2024-01-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-01 | 2024-01-30 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-03 | 2024-01-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-03 | 2024-01-04 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-12-05 | 2022-12-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-25 | 2022-11-20 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-10-25 | 2022-11-20 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-10-25 | 2022-11-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-10-25 | 2022-11-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-25 | 2022-11-20 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-10-25 | 2022-11-20 | 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 | 2022-10-25 | 2022-11-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-03-29 | 2021-04-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-29 | 2021-04-28 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-21 | 2019-11-22 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-10-21 | 2019-11-01 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-10-21 | 2019-11-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-22 | 2019-09-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-22 | 2019-09-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-08-22 | 2019-09-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-22 | 2019-09-21 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-08-22 | 2019-09-21 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-08-22 | 2019-09-21 | 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 | 2019-08-22 | 2019-09-21 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-08-22 | 2019-09-21 | 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 | 2019-08-22 | 2019-09-21 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-08-22 | 2019-09-21 | N |
