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Deficiency Records for University Health Lakewood Medical Center
View the most recent health deficiencies and inspection results for University Health Lakewood Medical Center. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for University Health Lakewood Medical Center. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| 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 | 2025-08-22 | 2025-10-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-08-22 | 2025-10-06 | 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 | 2025-08-22 | 2025-10-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2025-08-22 | 2025-10-06 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2025-08-22 | 2025-10-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2025-08-22 | 2025-10-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2025-08-22 | 2025-10-06 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2025-08-22 | 2025-10-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-08-22 | 2025-10-06 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2025-08-22 | 2025-10-06 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2025-08-22 | 2025-10-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-04-30 | 2025-04-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-04-30 | 2025-04-18 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-09-11 | 2024-10-23 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-09-11 | 2024-10-23 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2024-02-27 | 2024-04-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-27 | 2024-04-08 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 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 |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | 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 for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-11-14 | 2024-01-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-14 | 2024-01-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-02-27 | 2023-11-02 | Y |
| 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 |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-25 | 2022-05-06 | N |
| 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 |
| 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 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 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 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 |
| 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 |
| 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 |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2026-03-20 | Not Fixed | Y |