A list of the most recent deficiencies for University Post-Acute Rehab. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-28 | 2023-12-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-12 | 2023-01-23 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-01-27 | 2022-02-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-13 | 2022-02-11 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-01-13 | 2022-02-11 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-01-13 | 2022-02-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-01-13 | 2022-02-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-13 | 2022-02-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-13 | 2022-02-11 | 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 | 2022-01-13 | 2022-02-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-13 | 2022-02-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-13 | 2022-02-11 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-01-19 | 2022-01-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-19 | 2022-01-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-19 | 2022-01-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-19 | 2022-01-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-06 | 2019-08-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-06-06 | 2019-08-13 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-06-06 | 2019-08-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-06 | 2019-08-13 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-06-06 | 2019-08-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-06 | 2019-08-13 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-06-06 | 2019-08-13 | 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 | 2019-06-06 | 2019-08-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-06 | 2019-08-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-06 | 2019-08-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-06-06 | 2019-08-13 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-07-29 | 2019-08-12 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-07-29 | 2019-08-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-07-29 | 2019-08-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-29 | 2019-08-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-29 | 2019-08-12 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-05-10 | 2018-07-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-05-10 | 2018-07-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-05-17 | 2018-05-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-05-17 | 2018-05-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-17 | 2018-05-29 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-05-17 | 2018-05-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-17 | 2018-05-29 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-05-17 | 2018-05-29 | N |
