Deficiency Records for University Post Acute
Updated as of January 01, 2020
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? |
|---|---|---|---|---|
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-05-14 | 2019-07-08 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-05-14 | 2019-07-08 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-05-14 | 2019-07-08 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-05-14 | 2019-07-08 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-05-14 | 2019-07-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-05-14 | 2019-07-08 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2019-03-28 | 2019-04-25 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2019-03-28 | 2019-04-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-28 | 2019-04-25 | 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 ne | Health | 2019-03-28 | 2019-04-25 | 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 | 2019-03-28 | 2019-04-25 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-03-28 | 2019-04-25 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-03-28 | 2019-04-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-28 | 2019-04-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-28 | 2019-04-25 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-03-28 | 2019-04-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-28 | 2019-04-25 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-03-28 | 2019-04-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-08-07 | 2018-08-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-06-19 | 2018-08-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-19 | 2018-08-16 | Y |
| 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 |
