A list of the most recent deficiencies for Universal Health Care/north Raleigh. 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? |
|---|---|---|---|---|
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-19 | 2024-02-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-10 | 2024-02-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-10 | 2024-02-07 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-10 | 2024-02-07 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-30 | 2024-02-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-30 | 2024-02-07 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-12-19 | 2024-02-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-12-19 | 2024-02-02 | 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 | 2023-12-19 | 2024-02-02 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-12-19 | 2024-02-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-19 | 2024-02-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-12-19 | 2024-02-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-12-19 | 2024-02-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-12-19 | 2024-02-02 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-12-19 | 2024-02-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-19 | 2024-02-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-19 | 2024-02-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-12-19 | 2024-02-02 | N |
| 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 | 2023-11-30 | 2024-01-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-11-30 | 2024-01-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-30 | 2024-01-10 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-11-30 | 2024-01-10 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-11-30 | 2024-01-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-11-30 | 2024-01-10 | 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 | 2023-11-30 | 2024-01-10 | 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 | 2023-11-30 | 2024-01-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-30 | 2024-01-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-30 | 2024-01-10 | Y |
| 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 | 2024-01-10 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-02-16 | 2023-03-05 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-02-16 | 2023-03-03 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-18 | 2023-02-16 | Y |
| Meet other general requirements. | Fire Safety | 2022-09-07 | 2022-10-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-07 | 2022-10-22 | 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 | 2022-09-07 | 2022-10-22 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-09-07 | 2022-10-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-07 | 2022-10-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-09-07 | 2022-10-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-09-07 | 2022-10-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-09-07 | 2022-10-22 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-08-11 | 2022-09-16 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-08-11 | 2022-09-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-11 | 2022-09-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-11 | 2022-09-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-11 | 2022-09-16 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-08-11 | 2022-09-16 | N |
| Post nurse staffing information every day. | Health | 2022-08-11 | 2022-09-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-11 | 2022-09-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-11 | 2022-09-16 | 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 | 2022-08-11 | 2022-09-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-11 | 2022-09-16 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-08-11 | 2022-09-16 | Y |
| 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 | 2022-08-11 | 2022-09-16 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-11 | 2022-09-16 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-08-11 | 2022-09-16 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-08-11 | 2022-09-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-11 | 2022-09-16 | Y |
| 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 | 2022-08-11 | 2022-09-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-11 | 2022-09-09 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-08-11 | 2022-09-09 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-08-11 | 2022-09-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-11 | 2022-09-09 | 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 | 2022-08-11 | 2022-09-09 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-08-11 | 2022-09-09 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2022-08-11 | 2022-09-09 | N |
| Provide or obtain dental services for each resident. | Health | 2022-08-11 | 2022-09-06 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-08-11 | 2022-09-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-06 | 2021-05-19 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-05-06 | 2021-05-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-06 | 2021-05-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-01 | 2021-05-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-01 | 2021-05-04 | 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 | 2021-04-01 | 2021-05-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-01 | 2021-05-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-01 | 2021-05-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-01 | 2021-05-04 | Y |
