Deficiency Records for University Park Nursing and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for University Park 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? |
---|---|---|---|---|
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 | 2023-11-21 | 2023-12-15 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-21 | 2023-12-15 | 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 | 2023-11-21 | 2023-12-12 | Y |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-11-21 | 2023-12-12 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-21 | 2023-12-08 | Y |
Conduct testing and exercise requirements. | Fire Safety | 2023-02-08 | 2023-03-08 | 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 | 2023-02-02 | 2023-02-24 | N |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-02-02 | 2023-02-24 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-02-02 | 2023-02-24 | 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 | 2023-02-02 | 2023-02-24 | N |
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-02-02 | 2023-02-24 | N |
Provide and implement an infection prevention and control program. | Health | 2023-02-02 | 2023-02-24 | N |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-02-02 | 2023-02-24 | N |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-02-02 | 2023-02-24 | Y |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-02-08 | 2023-02-24 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-08 | 2023-02-24 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-08 | 2023-02-24 | N |
Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-02-08 | 2023-02-21 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-08 | 2023-02-13 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-10 | 2022-11-22 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-10 | 2022-11-22 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-10 | 2022-11-22 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-08 | 2022-10-13 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-08 | 2022-10-13 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-20 | 2022-01-20 | Y |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-20 | 2022-01-20 | Y |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-12-20 | 2022-01-20 | Y |
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-12-20 | 2022-01-20 | Y |
Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-12-20 | 2022-01-20 | Y |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-20 | 2022-01-20 | Y |
Provide and implement an infection prevention and control program. | Health | 2021-12-20 | 2022-01-20 | Y |
Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-12-20 | 2022-01-20 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-12-20 | 2022-01-20 | Y |
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 | 2021-07-07 | 2021-08-30 | 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 | 2021-07-12 | 2021-08-07 | 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 | 2021-07-12 | 2021-08-07 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-12 | 2021-08-07 | N |
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-07-12 | 2021-08-07 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-12 | 2021-08-07 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-12 | 2021-08-07 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-12 | 2021-08-07 | N |
Post nurse staffing information every day. | Health | 2021-07-12 | 2021-08-07 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-12 | 2021-08-07 | N |
Provide and implement an infection prevention and control program. | Health | 2021-07-12 | 2021-08-07 | N |
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 | 2021-07-12 | 2021-08-07 | N |
Meet requirements for the use of electrical equipment. | Fire Safety | 2021-07-07 | 2021-07-22 | 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 | 2021-07-07 | 2021-07-19 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-07 | 2021-07-19 | N |
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-07-07 | 2021-07-16 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-07 | 2021-07-14 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-07-07 | 2021-07-08 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-07 | 2021-07-08 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-07 | 2021-07-08 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-01 | 2021-04-26 | Y |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-01 | 2021-04-26 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-01 | 2021-04-26 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-01 | 2021-04-26 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-01 | 2021-04-26 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-01 | 2021-04-26 | Y |
Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-01 | 2021-04-26 | Y |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-04-01 | 2021-04-26 | Y |
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2021-04-01 | 2021-04-26 | Y |
Ensure that residents are free from significant medication errors. | Health | 2021-04-01 | 2021-04-26 | Y |
Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2021-04-01 | 2021-04-26 | Y |
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-04-01 | 2021-04-26 | Y |
Provide and implement an infection prevention and control program. | Health | 2021-04-01 | 2021-04-26 | Y |
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-04-01 | 2021-04-26 | Y |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-07-18 | 2019-08-15 | N |
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-07-18 | 2019-08-15 | 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 | 2019-07-18 | 2019-08-15 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-18 | 2019-08-15 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-07-18 | 2019-08-15 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-07-18 | 2019-08-15 | N |
Post nurse staffing information every day. | Health | 2019-07-18 | 2019-08-15 | 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 | 2019-07-18 | 2019-08-15 | 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 | 2019-07-18 | 2019-08-15 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-18 | 2019-08-15 | N |
Provide and implement an infection prevention and control program. | Health | 2019-07-18 | 2019-08-15 | N |
Use approved construction type or materials. | Fire Safety | 2019-07-23 | 2019-08-08 | N |
Have exits that are accessible at all times. | Fire Safety | 2019-07-23 | 2019-08-01 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-23 | 2019-08-01 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-07-23 | 2019-08-01 | N |