Deficiency Records for University Park Skilled Nursing and Therapy Memory
Updated as of March 01, 2024
A list of the most recent deficiencies for University Park Skilled Nursing and Therapy Memory. 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? |
|---|---|---|---|---|
| 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 | 2023-11-30 | 2023-12-27 | N |
| Provide activities to meet all resident's needs. | Health | 2023-11-30 | 2023-12-27 | 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 | 2023-11-30 | 2023-12-27 | 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 | 2023-11-30 | 2023-12-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-30 | 2023-12-27 | 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 | 2022-10-11 | 2022-11-10 | N |
| 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 | 2022-10-11 | 2022-11-10 | N |
| Respond appropriately to all alleged violations. | Health | 2022-10-11 | 2022-11-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-11 | 2022-11-10 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-10-11 | 2022-11-10 | 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 | 2022-10-11 | 2022-11-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-11 | 2022-11-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-11 | 2022-11-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-11 | 2022-11-10 | 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 | 2022-10-11 | 2022-11-10 | 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 | 2022-10-11 | 2022-11-10 | 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 | 2022-10-11 | 2022-11-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-10-11 | 2022-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-11 | 2022-11-10 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-10-11 | 2022-11-10 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-10-05 | 2022-11-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-10-05 | 2022-11-10 | 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 | 2022-10-05 | 2022-11-10 | 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 | 2022-10-05 | 2022-11-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-05 | 2022-11-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-05 | 2022-11-10 | 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 | 2021-04-07 | 2021-04-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-04-13 | 2021-04-16 | N |
| 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 | 2021-04-13 | 2021-04-16 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-04-13 | 2021-04-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-04-13 | 2021-04-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-13 | 2021-04-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-13 | 2021-04-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-13 | 2021-04-16 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-04-13 | 2021-04-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-04-13 | 2021-04-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-13 | 2021-04-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-13 | 2021-04-16 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-04-13 | 2021-04-16 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2019-01-08 | 2019-02-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-01-08 | 2019-02-06 | 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 | 2019-01-08 | 2019-02-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-08 | 2019-02-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-01-08 | 2019-02-06 | N |
