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Deficiency Records for University Park Rehabilitation and Healthcare
A list of the most recent deficiencies for University Park Rehabilitation and Healthcare. 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 Park Rehabilitation and Healthcare. 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? |
|---|---|---|---|---|
| Provide primary/alternate means for communication. | Fire Safety | 2024-07-18 | 2024-08-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-07-18 | 2024-08-17 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2024-06-25 | 2024-07-09 | 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 | 2024-06-06 | 2024-07-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-06 | 2024-07-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-06-06 | 2024-07-05 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-06-06 | 2024-07-05 | 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 | 2024-06-06 | 2024-07-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-06 | 2024-07-05 | N |
| Dispose of garbage and refuse properly. | Health | 2024-06-06 | 2024-07-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-06-06 | 2024-07-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-06-06 | 2024-07-05 | 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 | 2024-03-26 | 2024-04-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-14 | 2024-02-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-06 | 2023-12-15 | Y |
| 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 | 2023-12-06 | 2023-12-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-12 | 2023-10-31 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-07-06 | 2023-08-10 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-07-06 | 2023-08-10 | 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 | 2023-07-06 | 2023-08-10 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-07-06 | 2023-08-10 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-07-06 | 2023-08-10 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-07-06 | 2023-08-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-06 | 2023-08-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-06 | 2023-08-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-06 | 2023-08-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-06 | 2023-08-10 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-07-06 | 2023-08-10 | N |
| Post nurse staffing information every day. | Health | 2023-06-16 | 2023-07-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-16 | 2023-07-05 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-06-16 | 2023-07-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-25 | 2023-06-13 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-05-25 | 2023-06-13 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-25 | 2023-06-13 | Y |
| Meet other general requirements. | Fire Safety | 2023-04-28 | 2023-05-19 | Y |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-28 | 2023-05-19 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-28 | 2023-05-19 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-10-04 | 2022-12-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-10-04 | 2022-12-22 | 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 | 2022-10-04 | 2022-12-22 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-10-04 | 2022-12-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-04 | 2022-12-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-01 | 2022-12-15 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-10-04 | 2022-11-06 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-10-04 | 2022-11-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-04 | 2022-11-06 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-10-04 | 2022-11-06 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-10-04 | 2022-11-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-04 | 2022-11-06 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-10-04 | 2022-11-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-04 | 2022-11-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-04 | 2022-11-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-04 | 2022-11-06 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-10-04 | 2022-11-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-04 | 2022-11-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-04 | 2022-11-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-04 | 2022-11-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-28 | 2022-10-14 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-09-28 | 2022-10-14 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-28 | 2022-10-14 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-08-23 | 2022-09-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-23 | 2022-09-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-23 | 2022-09-02 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-08-23 | 2022-09-02 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-08-23 | 2022-09-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-23 | 2022-09-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-08 | 2022-04-20 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-04-08 | 2022-04-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-08 | 2022-04-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-08 | 2022-04-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-08 | 2022-04-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-13 | 2021-12-27 | Y |
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