Deficiency Records for University Post Acute
Updated as of May 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? |
---|---|---|---|---|
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-10 | 2020-03-02 | Y |
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 |