A list of the most recent deficiencies for Universal Health Care and Rehab. 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? |
|---|---|---|---|---|
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-10-17 | 2023-10-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-17 | 2023-10-18 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-10-17 | 2023-10-18 | 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 | 2023-01-04 | 2023-05-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-04 | 2023-05-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-04 | 2023-05-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-04 | 2023-05-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-08 | 2022-12-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-08 | 2022-12-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-08 | 2022-12-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-08 | 2022-12-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-08 | 2022-12-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-12-08 | 2022-12-29 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-07-15 | 2021-10-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-15 | 2021-10-11 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-07-15 | 2021-10-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-20 | 2021-10-11 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-07-15 | 2021-09-20 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-07-15 | 2021-09-20 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-07-15 | 2021-09-20 | Y |
| 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 | 2021-07-15 | 2021-09-20 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-15 | 2021-09-20 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-15 | 2021-09-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-15 | 2021-09-20 | Y |
| Provide appropriate foot care. | Health | 2021-07-15 | 2021-09-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-15 | 2021-09-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-23 | 2019-07-15 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-05-23 | 2019-07-15 | 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 | 2019-06-25 | 2019-07-11 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2019-06-25 | 2019-07-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-23 | 2019-06-20 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-05-23 | 2019-06-20 | 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 | 2019-05-23 | 2019-06-20 | 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 | 2019-05-23 | 2019-06-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-05-23 | 2019-06-20 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-05-23 | 2019-06-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-23 | 2019-06-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-05-23 | 2019-06-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-23 | 2019-06-20 | 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 | 2019-05-23 | 2019-06-20 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2019-05-23 | 2019-06-20 | N |
| Post nurse staffing information every day. | Health | 2019-05-23 | 2019-06-20 | 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 | 2019-05-23 | 2019-06-20 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-05-23 | 2019-06-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-23 | 2019-06-20 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-05-23 | 2019-06-20 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-05-23 | 2019-06-20 | N |
