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Deficiency Records for University Heights Health and Living Community
A list of the most recent deficiencies for University Heights Health and Living Community. 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 Health and Living Community. 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-08-27 | 2024-09-18 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2024-08-27 | 2024-09-18 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-08-27 | 2024-09-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-27 | 2024-09-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-27 | 2024-09-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-08-27 | 2024-09-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-09-03 | 2024-09-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-09-03 | 2024-09-18 | 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 | 2024-09-03 | 2024-09-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-09-03 | 2024-09-18 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2024-09-03 | 2024-09-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-09-03 | 2024-09-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-09-03 | 2024-09-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-09-03 | 2024-09-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-09-03 | 2024-09-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-09-03 | 2024-09-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-09-03 | 2024-09-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-09-03 | 2024-09-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-09-03 | 2024-09-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-23 | 2024-06-10 | Y |
| 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 | 2024-05-23 | 2024-06-10 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-31 | 2023-12-29 | 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 | 2023-10-31 | 2023-12-29 | 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 | 2023-10-31 | 2023-12-29 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-10-31 | 2023-12-29 | 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 | 2023-10-31 | 2023-12-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-31 | 2023-12-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-31 | 2023-12-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-31 | 2023-12-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-31 | 2023-12-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-31 | 2023-12-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-31 | 2023-12-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-31 | 2023-12-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-31 | 2023-12-29 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-05 | 2023-12-23 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-12-05 | 2023-12-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-19 | 2023-10-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-22 | 2023-10-06 | 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 | 2023-09-22 | 2023-10-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-13 | 2023-07-29 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2022-09-28 | 2022-10-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-28 | 2022-10-28 | 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 | 2022-09-28 | 2022-10-28 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2022-09-28 | 2022-10-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-09-28 | 2022-10-28 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-09-28 | 2022-10-28 | 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 | 2022-09-28 | 2022-10-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-09-28 | 2022-10-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-28 | 2022-10-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-28 | 2022-10-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-09-28 | 2022-10-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-28 | 2022-10-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-09-28 | 2022-10-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-28 | 2022-10-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-28 | 2022-10-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-28 | 2022-10-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-08-22 | 2022-09-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-08-22 | 2022-09-02 | 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 | 2022-09-28 | Not Fixed | N |
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