Deficiency Records for University Park Nursing and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for University Park Nursing and Rehabilitation. 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 and implement an infection prevention and control program. | Health | 2024-01-30 | 2024-01-31 | Y |
| Assess the resident when there is a significant change in condition | Health | 2023-12-07 | 2023-12-22 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-07 | 2023-12-22 | 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 | 2023-12-07 | 2023-12-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-07 | 2023-12-22 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-04-04 | 2023-05-27 | 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 | 2023-04-04 | 2023-05-27 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-04-04 | 2023-05-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-04 | 2023-05-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-13 | 2023-04-13 | Y |
| Assess the resident when there is a significant change in condition | Health | 2023-04-04 | 2023-04-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-04-04 | 2023-04-05 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2023-04-04 | 2023-04-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-04 | 2023-04-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-04 | 2023-04-05 | N |
| Post nurse staffing information every day. | Health | 2023-04-04 | 2023-04-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-04 | 2023-04-05 | N |
| Keep all essential equipment working safely. | Health | 2023-04-04 | 2023-04-05 | 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 | 2023-04-04 | 2023-04-05 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-04-04 | 2023-04-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-04 | 2023-04-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-04 | 2023-04-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-04 | 2023-04-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-04 | 2023-04-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-01-26 | 2023-03-08 | 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 | 2023-01-26 | 2023-03-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-26 | 2023-03-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-26 | 2022-06-17 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-03-10 | 2022-04-08 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-03-10 | 2022-04-08 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-03-08 | 2022-04-08 | 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 | 2022-03-08 | 2022-04-08 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-03-08 | 2022-04-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-03-08 | 2022-03-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-10 | 2022-03-11 | 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 | 2022-03-10 | 2022-03-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-10 | 2022-03-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-01-06 | 2022-01-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-06 | 2022-01-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-26 | 2021-08-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-26 | 2021-08-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-26 | 2021-08-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-17 | 2021-08-27 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-03-19 | 2021-07-23 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-03-19 | 2021-04-18 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-03-19 | 2021-04-18 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-03-19 | 2021-04-18 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-03-19 | 2021-04-18 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-03-19 | 2021-04-18 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-03-19 | 2021-04-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-03-19 | 2021-04-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-03-19 | 2021-04-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-03-19 | 2021-04-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-19 | 2021-04-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-03-19 | 2021-04-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-19 | 2021-04-18 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2021-03-19 | 2021-04-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-19 | 2021-04-18 | N |
