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? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2022-01-24 | 2022-02-08 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2022-01-24 | 2022-02-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-24 | 2022-02-08 | 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 | 2022-01-24 | 2022-02-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-24 | 2022-02-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-01-24 | 2022-02-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-24 | 2022-02-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-24 | 2022-02-08 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-01-24 | 2022-02-08 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-01-25 | 2022-02-08 | 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 | 2022-01-25 | 2022-02-08 | 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 | 2022-01-25 | 2022-02-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-25 | 2022-02-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-25 | 2022-02-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-25 | 2022-02-08 | N |
| 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 |
| 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 | 2019-05-14 | 2019-07-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-05-14 | 2019-07-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-14 | 2019-07-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-14 | 2019-07-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-14 | 2019-07-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 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 necessary and PRN use is limited. | 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 |
| 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 |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-30 | 2018-06-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-30 | 2018-06-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-30 | 2018-06-26 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-05-30 | 2018-06-26 | N |
| 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 |
