Deficiency Records for University Post Acute
Updated as of October 01, 2018
This is not the most recent data for University Post Acute. For the most recent information, click here.
A list of the most recent deficiencies for University Post Acute. 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 treatment and care according to orders, resident?s preferences and goals. | Health | 2018-07-16 | 2018-07-31 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-05-30 | 2018-06-26 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-05-30 | 2018-06-26 | N |
| Develop a communication plan. | Fire Safety | 2018-05-30 | 2018-06-26 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-05-30 | 2018-06-26 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-05-30 | 2018-06-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-05-16 | 2018-05-29 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-03-16 | 2018-04-09 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-03-16 | 2018-04-09 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2018-03-16 | 2018-04-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-16 | 2018-04-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-03-16 | 2018-04-09 | 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 | 2018-03-16 | 2018-04-09 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2018-03-16 | 2018-04-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-03-16 | 2018-04-09 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-03-16 | 2018-04-09 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-03-16 | 2018-04-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-16 | 2018-04-09 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-03-16 | 2018-04-09 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-02-22 | 2018-03-09 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-11-03 | 2017-12-06 | Y |
| Operate and provide services according to Federal, State, and local laws and professional standards. | Health | 2017-11-03 | 2017-12-06 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-11-20 | 2017-11-30 | Y |
| Try to resolve each resident's complaints quickly. | Health | 2017-10-26 | 2017-11-07 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-10-23 | 2017-11-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-10-23 | 2017-11-07 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-08-01 | 2017-08-14 | Y |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2017-02-17 | 2017-03-21 | N |
| Completely assess the resident at least every twelve months. | Health | 2017-02-17 | 2017-03-21 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-02-17 | 2017-03-21 | N |
| Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. | Health | 2017-02-17 | 2017-03-21 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-02-17 | 2017-03-21 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-02-17 | 2017-03-21 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2017-02-17 | 2017-03-21 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-02-17 | 2017-03-21 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-02-17 | 2017-03-21 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-02-10 | 2017-03-13 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-11-10 | 2016-11-28 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-03-25 | 2016-05-24 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2016-03-25 | 2016-05-23 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-03-25 | 2016-05-23 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-03-25 | 2016-05-23 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2016-03-25 | 2016-05-23 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2016-03-25 | 2016-05-23 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-03-25 | 2016-05-23 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2016-03-25 | 2016-05-23 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2016-03-25 | 2016-05-23 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-03-25 | 2016-05-23 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2016-03-25 | 2016-05-23 | N |
| Properly located and lighted "Exit" signs. | Fire Safety | 2016-04-21 | 2016-05-16 | N |
| Properly working alarms on sprinkler valves. | Fire Safety | 2016-04-21 | 2016-05-16 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-04-21 | 2016-05-16 | N |
| Portable fire extinguishers. | Fire Safety | 2016-04-21 | 2016-05-16 | N |
| Restrictions on the use of highly flammable decorations. | Fire Safety | 2016-04-21 | 2016-05-16 | N |
| Proper medical gas storage and administration areas. | Fire Safety | 2016-04-21 | 2016-05-16 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-04-21 | 2016-05-16 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2015-12-28 | 2016-01-11 | Y |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2015-11-12 | 2015-12-09 | Y |
