A list of the most recent deficiencies for Universal Health Care Lillington. 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? |
---|---|---|---|---|
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 | 2023-11-30 | 2023-12-18 | Y |
Ensure each resident receives an accurate assessment. | Health | 2023-04-11 | 2023-05-08 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-04-11 | 2023-05-08 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-11 | 2023-05-08 | 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 | 2023-04-11 | 2023-05-08 | Y |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-04-11 | 2023-05-08 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-11 | 2023-04-11 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-11 | 2023-04-11 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-21 | 2022-04-27 | Y |
Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-04 | 2022-03-15 | N |
Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-02-04 | 2022-03-15 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-04 | 2022-03-15 | N |
Provide activities to meet all resident's needs. | Health | 2022-02-04 | 2022-03-15 | N |
Ensure the activities program is directed by a qualified professional. | Health | 2022-02-04 | 2022-03-15 | N |
Provide appropriate foot care. | Health | 2022-02-04 | 2022-03-15 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-04 | 2022-03-15 | N |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-02-04 | 2022-03-15 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-04 | 2022-03-15 | N |
Post nurse staffing information every day. | Health | 2022-02-04 | 2022-03-15 | N |
Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-02-04 | 2022-03-15 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-04 | 2022-03-15 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-04 | 2022-03-15 | N |
Provide and implement an infection prevention and control program. | Health | 2022-02-04 | 2022-03-15 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-04 | 2022-03-15 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-04 | 2022-03-15 | Y |
Report COVID19 data to residents and families. | Health | 2022-02-04 | 2022-03-15 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-04 | 2022-03-15 | Y |
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 | 2022-03-03 | 2022-02-28 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 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 |