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Deficiency Records for Universal Health Care/ Concord
A list of the most recent deficiencies for Universal Health Care/ Concord. 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 Universal Health Care/ Concord. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-08-29 | 2024-10-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-29 | 2024-10-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-29 | 2024-10-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-29 | 2024-10-01 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-08-29 | 2024-10-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-07-16 | 2024-08-29 | 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 | 2024-05-16 | 2024-05-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-05-16 | 2024-05-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-16 | 2024-05-30 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-04-18 | 2024-05-09 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-04-18 | 2024-05-08 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-04-18 | 2024-05-08 | 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 | 2024-04-18 | 2024-05-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-04-18 | 2024-05-08 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-04-18 | 2024-05-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-18 | 2024-05-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-04-18 | 2024-05-08 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-04-18 | 2024-05-08 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-04-18 | 2024-05-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-04-18 | 2024-05-08 | 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 | 2024-04-18 | 2024-05-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-18 | 2024-05-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-04-18 | 2024-05-08 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-04-18 | 2024-05-08 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-04-18 | 2024-05-08 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-10-17 | 2023-10-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-17 | 2023-10-18 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-10-17 | 2023-10-18 | 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 | 2023-01-04 | 2023-05-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-04 | 2023-05-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-04 | 2023-05-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-04 | 2023-05-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-08 | 2022-12-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-08 | 2022-12-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-08 | 2022-12-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-08 | 2022-12-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-08 | 2022-12-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-12-08 | 2022-12-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-15 | 2021-10-11 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-07-15 | 2021-10-11 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-07-15 | 2021-10-11 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-07-15 | 2021-09-20 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-07-15 | 2021-09-20 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-07-15 | 2021-09-20 | 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 | 2021-07-15 | 2021-09-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-15 | 2021-09-20 | 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 | 2021-07-15 | 2021-09-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-15 | 2021-09-20 | N |
| Provide appropriate foot care. | Health | 2021-07-15 | 2021-09-20 | N |
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