Deficiency Records for Universal Health Care Lillington
Updated as of April 01, 2020
This is not the most recent data for Universal Health Care Lillington. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Keep residents' personal and medical records private and confidential. | Health | 2019-11-22 | 2019-12-20 | 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 | 2019-11-22 | 2019-12-20 | 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 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-19 | 2019-03-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-19 | 2019-03-20 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-02-19 | 2019-03-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-25 | 2018-10-19 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-06-08 | 2018-07-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-06-08 | 2018-07-10 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-06-08 | 2018-07-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-06-08 | 2018-07-10 | N |
| Respond appropriately to all alleged violations. | Health | 2018-06-08 | 2018-07-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-06-08 | 2018-07-10 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-06-08 | 2018-07-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-06-08 | 2018-07-10 | 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 | 2018-06-08 | 2018-07-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-06-08 | 2018-07-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-06-08 | 2018-07-10 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-06-08 | 2018-07-10 | 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 | 2018-06-08 | 2018-07-10 | 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 | 2018-06-08 | 2018-07-10 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-06-08 | 2018-07-10 | 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 | 2018-06-08 | 2018-07-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-08 | 2018-07-10 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-06-08 | 2018-07-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-06-08 | 2018-07-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2017-12-08 | 2017-12-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-11-16 | 2017-12-28 | Y |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-11-16 | 2017-12-28 | Y |
| Protect each resident from mistreatment, neglect and misappropriation of personal property. | Health | 2017-11-16 | 2017-12-28 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-11-16 | 2017-12-28 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-11-16 | 2017-12-28 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-11-16 | 2017-12-28 | Y |
| Ensure that residents are safe from serious medication errors. | Health | 2017-11-16 | 2017-12-28 | Y |
