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Deficiency Records for Universal Health Care/lillington
A list of the most recent deficiencies for Universal Health Care/lillington. 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/lillington. 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? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-05-23 | 2024-06-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-23 | 2024-06-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-23 | 2024-06-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-04-26 | 2024-05-24 | 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 | 2024-04-26 | 2024-05-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-26 | 2024-05-24 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-04-26 | 2024-05-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-26 | 2024-05-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-26 | 2024-05-24 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-04-26 | 2024-05-24 | Y |
| 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 | 2023-11-30 | 2023-12-18 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-11 | 2023-05-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-04-11 | 2023-05-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-11 | 2023-05-08 | 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 | 2023-04-11 | 2023-05-08 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-04-11 | 2023-05-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-11 | 2023-04-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-11 | 2023-04-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-21 | 2022-04-27 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-04 | 2022-03-15 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-02-04 | 2022-03-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-04 | 2022-03-15 | N |
| Provide activities to meet all resident's needs. | Health | 2022-02-04 | 2022-03-15 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-02-04 | 2022-03-15 | N |
| Provide appropriate foot care. | Health | 2022-02-04 | 2022-03-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-04 | 2022-03-15 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-02-04 | 2022-03-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-04 | 2022-03-15 | N |
| Post nurse staffing information every day. | Health | 2022-02-04 | 2022-03-15 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-02-04 | 2022-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-04 | 2022-03-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-04 | 2022-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-04 | 2022-03-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-04 | 2022-03-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-04 | 2022-03-15 | Y |
| Report COVID19 data to residents and families. | Health | 2022-02-04 | 2022-03-15 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-04 | 2022-03-15 | 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 | 2022-03-03 | 2022-02-28 | Y |
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