Deficiency Records for University Health Lakewood Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for University Health Lakewood Care 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 for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-11-14 | 2024-01-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-14 | 2024-01-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-14 | 2024-01-03 | 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 | 2023-11-14 | 2024-01-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-14 | 2024-01-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-14 | 2024-01-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-30 | 2023-01-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-30 | 2023-01-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-25 | 2022-05-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-25 | 2022-05-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-25 | 2022-05-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-03-25 | 2022-05-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-25 | 2022-05-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-25 | 2022-05-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-25 | 2022-05-05 | 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 | 2022-03-25 | 2022-05-05 | 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 | 2022-03-25 | 2022-05-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-25 | 2022-05-02 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-03-25 | 2022-05-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-25 | 2022-04-19 | N |
| 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 | 2022-03-25 | 2022-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-25 | 2022-03-25 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-03-25 | 2022-03-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-25 | 2022-03-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-25 | 2022-03-25 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-03-25 | 2022-03-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-25 | 2022-03-25 | 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 | 2019-05-30 | 2019-07-11 | N |
