Deficiency Records for Urbana Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Urbana Health and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-10-02 | 2023-10-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-09 | 2023-03-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-09 | 2023-03-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-09 | 2023-03-10 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-10-13 | 2022-11-30 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-10-13 | 2022-11-30 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-10-13 | 2022-11-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-13 | 2022-11-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-13 | 2022-11-30 | 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 | 2022-10-13 | 2022-11-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-13 | 2022-11-30 | 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 | 2022-10-13 | 2022-11-30 | 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 | 2022-10-13 | 2022-11-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-11 | 2022-11-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-10-11 | 2022-11-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-11 | 2022-11-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-11 | 2022-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-15 | 2021-04-07 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-11-06 | 2019-12-13 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-11-06 | 2019-12-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-11-06 | 2019-12-13 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2019-11-06 | 2019-12-13 | N |
| Provide activities to meet all resident's needs. | Health | 2019-11-06 | 2019-12-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-11-06 | 2019-12-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-11-06 | 2019-12-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-06 | 2019-12-13 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-11-05 | 2019-12-13 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-11-05 | 2019-12-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-11-05 | 2019-12-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-06 | 2019-10-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-10-12 | 2018-11-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-10-12 | 2018-11-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-10-12 | 2018-11-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-12 | 2018-11-14 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-10-12 | 2018-11-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-12 | 2018-11-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-12 | 2018-11-14 | 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 | 2018-10-12 | 2018-11-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-12 | 2018-11-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-12 | 2018-11-14 | 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 | 2018-10-12 | 2018-11-14 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-10-12 | 2018-11-14 | 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 | 2018-10-12 | 2018-11-14 | 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 | 2018-10-12 | 2018-11-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-10-12 | 2018-11-14 | N |
| Have policies on smoking. | Health | 2018-10-12 | 2018-11-14 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-10-11 | 2018-11-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-10-11 | 2018-11-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-11 | 2018-11-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-10-11 | 2018-11-14 | N |
