Deficiency Records for University Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for University Nursing 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? |
|---|---|---|---|---|
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-04 | 2023-05-18 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-24 | 2022-09-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-01 | 2022-08-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-01 | 2022-08-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-01 | 2022-08-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-01 | 2022-08-19 | Y |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2021-05-24 | 2021-07-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-24 | 2021-07-16 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-05-24 | 2021-07-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-05-19 | 2021-06-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-19 | 2021-06-18 | N |
| Respond appropriately to all alleged violations. | Health | 2021-05-19 | 2021-06-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-19 | 2021-06-18 | 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 | 2021-05-19 | 2021-06-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-19 | 2021-06-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-05-19 | 2021-06-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-19 | 2021-06-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-04 | 2020-01-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-04 | 2020-01-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-04 | 2020-01-21 | N |
| 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 | 2019-09-16 | 2019-10-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-16 | 2019-10-16 | N |
| 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 | 2019-09-16 | 2019-10-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-16 | 2019-10-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-16 | 2019-10-16 | 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 | 2019-09-16 | 2019-10-16 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-09-16 | 2019-10-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-16 | 2019-10-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-16 | 2019-10-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-16 | 2019-10-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-16 | 2019-10-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-16 | 2019-10-16 | N |
| Post nurse staffing information every day. | Health | 2019-09-16 | 2019-10-16 | 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 | 2019-09-16 | 2019-10-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-16 | 2019-10-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-16 | 2019-10-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-09-16 | 2019-10-16 | N |
