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Deficiency Records for University Heights Care Center
A list of the most recent deficiencies for University Heights Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for University Heights Care Center. 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? |
|---|---|---|---|---|
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2024-02-15 | 2024-05-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-15 | 2024-05-17 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-01-24 | 2024-01-25 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-01-24 | 2024-01-25 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-01-24 | 2024-01-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-24 | 2024-01-25 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-01-24 | 2024-01-25 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-01-24 | 2024-01-25 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-01-24 | 2024-01-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-01-24 | 2024-01-25 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-01-24 | 2024-01-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-24 | 2024-01-25 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-01-24 | 2024-01-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-24 | 2024-01-25 | N |
| Dispose of garbage and refuse properly. | Health | 2024-01-24 | 2024-01-25 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-01-24 | 2024-01-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-24 | 2024-01-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-24 | 2024-01-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-24 | 2024-01-25 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2024-01-24 | 2024-01-25 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-01-24 | 2024-01-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-19 | 2023-07-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-19 | 2023-07-19 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-10-26 | 2022-12-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-26 | 2022-11-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-26 | 2022-11-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-26 | 2022-11-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-26 | 2022-11-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-29 | 2022-09-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-29 | 2022-09-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-29 | 2022-09-30 | N |
| Provide activities to meet all resident's needs. | Health | 2022-09-29 | 2022-09-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-29 | 2022-09-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-29 | 2022-09-30 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-09-29 | 2022-09-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-29 | 2022-09-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-29 | 2022-09-30 | 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 | 2022-09-29 | 2022-09-30 | 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 | 2022-09-29 | 2022-09-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-29 | 2022-09-30 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-09-29 | 2022-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-29 | 2022-09-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-14 | 2021-07-23 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-07-14 | 2021-07-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-14 | 2021-07-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-22 | 2021-06-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-06-22 | 2021-06-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-22 | 2021-06-23 | N |
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