A list of the most recent deficiencies for Universal Health Care/fuquay-Varina. 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 aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-16 | 2023-12-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-16 | 2023-12-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-16 | 2023-12-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-16 | 2023-12-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-16 | 2023-12-22 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-10-18 | 2023-11-13 | 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 | 2023-10-18 | 2023-11-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-18 | 2023-11-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-18 | 2023-11-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-18 | 2023-11-13 | 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 | 2023-10-18 | 2023-11-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-10-18 | 2023-11-13 | 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 | 2023-10-18 | 2023-11-13 | 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 | 2023-10-18 | 2023-11-13 | 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 | 2023-10-18 | 2023-11-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-18 | 2023-11-13 | N |
| Dispose of garbage and refuse properly. | Health | 2023-10-18 | 2023-11-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-18 | 2023-11-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-10-18 | 2023-11-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-18 | 2023-11-13 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-10-18 | 2023-11-13 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-10-18 | 2023-11-13 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-10-18 | 2023-11-13 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-10-18 | 2023-11-13 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-10-18 | 2023-11-13 | 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 | 2023-10-18 | 2023-11-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-18 | 2023-11-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-18 | 2023-11-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-18 | 2023-11-13 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-10-18 | 2023-11-13 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-18 | 2023-11-13 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-10-18 | 2023-11-13 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-10-18 | 2023-11-13 | 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 | 2022-07-14 | 2022-09-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-14 | 2022-09-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-14 | 2022-09-27 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-14 | 2022-09-27 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-07-14 | 2022-09-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-17 | 2022-07-15 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-06-17 | 2022-07-15 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-06-17 | 2022-07-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-17 | 2022-07-15 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-06-17 | 2022-07-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-17 | 2022-07-15 | N |
| Dispose of garbage and refuse properly. | Health | 2022-06-17 | 2022-07-15 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-06-17 | 2022-07-15 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-06-17 | 2022-07-15 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-06-17 | 2022-07-15 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-06-17 | 2022-07-15 | 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 | 2022-06-17 | 2022-07-15 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-06-17 | 2022-07-15 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-06-17 | 2022-07-15 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-17 | 2022-07-15 | 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 | 2022-06-17 | 2022-07-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-17 | 2022-07-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-17 | 2022-07-15 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-06-17 | 2022-07-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-17 | 2022-07-15 | Y |
| 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 | 2022-06-17 | 2022-07-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-06-17 | 2022-07-15 | Y |
| 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 | 2022-06-17 | 2022-07-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-17 | 2022-07-15 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-06-17 | 2022-07-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-17 | 2022-07-15 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-17 | 2022-07-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-20 | 2021-10-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-20 | 2021-10-01 | Y |
| 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 | 2021-06-11 | 2021-09-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-20 | 2021-09-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-11 | 2021-08-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-11 | 2021-08-06 | 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 | 2021-06-11 | 2021-08-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-11 | 2021-08-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-11 | 2021-08-06 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-11 | 2021-08-06 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-06-11 | 2021-08-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-06-11 | 2021-08-06 | 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 | 2021-06-11 | 2021-08-06 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-06-11 | 2021-08-06 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-06-11 | 2021-08-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-11 | 2021-08-06 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-06-11 | 2021-08-06 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2021-06-11 | 2021-08-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-11 | 2021-08-06 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-06-11 | 2021-08-06 | 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 | 2021-06-11 | 2021-08-06 | 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 | 2021-06-11 | 2021-08-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-11 | 2021-08-06 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-06-11 | 2021-08-06 | 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 | 2021-06-11 | 2021-08-06 | Y |
| 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 | 2021-04-05 | 2021-06-11 | Y |
