A list of the most recent deficiencies for University Manor Health and Reha. 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? |
|---|---|---|---|---|
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-12 | 2023-10-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-12 | 2023-10-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-12 | 2023-10-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-12 | 2023-10-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-12 | 2023-10-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-12 | 2023-10-25 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-09-12 | 2023-10-25 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-07-18 | 2023-10-25 | 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 | 2023-04-13 | 2023-05-04 | 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 | 2023-04-13 | 2023-05-04 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-13 | 2023-05-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-13 | 2023-05-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-18 | 2023-03-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-18 | 2023-03-08 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-05-19 | 2022-07-01 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-05-19 | 2022-07-01 | 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 | 2022-05-19 | 2022-07-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-19 | 2022-07-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-05-19 | 2022-07-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-19 | 2022-07-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-18 | 2022-07-01 | 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 | 2022-05-18 | 2022-07-01 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-05-18 | 2022-07-01 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-05-18 | 2022-07-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-18 | 2022-07-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-18 | 2022-07-01 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-05-18 | 2022-07-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-05-18 | 2022-07-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-18 | 2022-07-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-18 | 2022-07-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-05-18 | 2022-07-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-05-18 | 2022-07-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-18 | 2022-07-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-18 | 2022-07-01 | 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 | 2022-04-04 | 2022-04-26 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-03-11 | 2022-04-26 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-03-11 | 2022-04-26 | 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 | 2022-03-11 | 2022-04-26 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-11 | 2022-04-26 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-11 | 2022-04-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-11 | 2022-04-26 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-12-30 | 2022-02-07 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-12-30 | 2022-02-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-09 | 2021-10-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-09 | 2021-10-06 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-09 | 2021-10-06 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2021-08-05 | 2021-08-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-10 | 2021-07-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-10 | 2021-07-15 | 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 | 2021-06-10 | 2021-07-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-20 | 2021-04-30 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-20 | 2021-04-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-20 | 2021-04-30 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-04-18 | 2019-05-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-18 | 2019-05-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-18 | 2019-05-24 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-04-18 | 2019-05-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-18 | 2019-05-24 | 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 | 2019-04-18 | 2019-05-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-18 | 2019-05-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-18 | 2019-05-24 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-04-18 | 2019-05-24 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-04-16 | 2019-05-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-16 | 2019-05-24 | N |
| Use approved construction type or materials. | Fire Safety | 2019-04-16 | 2019-05-24 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-04-16 | 2019-05-24 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-04-16 | 2019-05-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-16 | 2019-05-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-04-16 | 2019-05-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-16 | 2019-05-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-04-16 | 2019-05-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-16 | 2019-05-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-04-16 | 2019-05-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-16 | 2019-05-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-16 | 2019-05-24 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-03-01 | 2018-04-11 | N |
| 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 | 2018-03-01 | 2018-04-11 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-03-01 | 2018-04-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-03-01 | 2018-04-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-01 | 2018-04-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-03-01 | 2018-04-11 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-03-01 | 2018-04-11 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-03-01 | 2018-04-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-01 | 2018-04-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-01 | 2018-04-11 | N |
| Dispose of garbage and refuse properly. | Health | 2018-03-01 | 2018-04-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-01 | 2018-04-11 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2018-03-01 | 2018-04-11 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-03-01 | 2018-04-11 | N |
| Use approved construction type or materials. | Fire Safety | 2018-02-27 | 2018-04-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-02-27 | 2018-04-11 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-02-27 | 2018-04-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-02-27 | 2018-04-11 | 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 | 2018-02-27 | 2018-04-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-02-27 | 2018-04-11 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-02-27 | 2018-04-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-02-27 | 2018-04-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-02-27 | 2018-04-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-02-27 | 2018-04-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-02-27 | 2018-04-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-02-27 | 2018-04-11 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-02-27 | 2018-04-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-02-27 | 2018-04-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-02-27 | 2018-04-11 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-02-27 | 2018-04-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-02-27 | 2018-04-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-02-27 | 2018-04-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-02-27 | 2018-04-11 | N |
