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Deficiency Records for University Manor Health and Reha

A list of the most recent deficiencies for University Manor Health and Reha. 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 Manor Health and Reha. 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?
Observe each nurse aide's job performance and give regular training. Health 2024-04-22 2024-05-10 Y
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2024-04-22 2024-05-10 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-04-22 2024-03-21 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-10-12 2023-10-25 Y
Provide and implement an infection prevention and control program. Health 2023-10-12 2023-10-25 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-09-12 2023-10-25 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-09-12 2023-10-25 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-09-12 2023-10-25 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-09-12 2023-10-25 Y
Provide behavior health training consistent with the requirements and as determined by a facility assessment. Health 2023-09-12 2023-10-25 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2023-07-18 2023-10-25 Y
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 2023-04-13 2023-05-04 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 2023-04-13 2023-05-04 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-04-13 2023-05-04 Y
Provide and implement an infection prevention and control program. Health 2023-04-13 2023-05-04 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-02-18 2023-03-08 Y
Respond appropriately to all alleged violations. Health 2023-02-18 2023-03-08 Y
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Health 2022-05-19 2022-07-01 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2022-05-19 2022-07-01 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 2022-05-19 2022-07-01 N
Provide enough food/fluids to maintain a resident's health. Health 2022-05-19 2022-07-01 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2022-05-19 2022-07-01 N
Provide and implement an infection prevention and control program. Health 2022-05-19 2022-07-01 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2022-05-18 2022-07-01 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 2022-05-18 2022-07-01 N
Have stairways and smokeproof enclosures used as exits that meet safety requirements. Fire Safety 2022-05-18 2022-07-01 N
Have an enclosure around a vertical opening shaft. Fire Safety 2022-05-18 2022-07-01 N
Provide properly protected cooking facilities. Fire Safety 2022-05-18 2022-07-01 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-05-18 2022-07-01 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2022-05-18 2022-07-01 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2022-05-18 2022-07-01 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-05-18 2022-07-01 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2022-05-18 2022-07-01 N
Provide a written emergency evacuation plan. Fire Safety 2022-05-18 2022-07-01 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2022-05-18 2022-07-01 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-05-18 2022-07-01 N
Ensure proper usage of power strips and extension cords. Fire Safety 2022-05-18 2022-07-01 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 2022-04-04 2022-04-26 Y
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2022-03-11 2022-04-26 Y
Ensure that the resident and his/her doctor meet face-to-face at all required visits. Health 2022-03-11 2022-04-26 Y
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2022-03-11 2022-04-26 Y
Ensure medication error rates are not 5 percent or greater. Health 2022-03-11 2022-04-26 Y
Ensure that residents are free from significant medication errors. Health 2022-03-11 2022-04-26 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-03-11 2022-04-26 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2021-12-30 2022-02-07 Y
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Health 2021-12-30 2022-02-07 Y
Ensure residents have reasonable access to and privacy in their use of communication methods. Health 2019-04-18 2019-05-24 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-04-18 2019-05-24 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2019-04-18 2019-05-24 N
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Health 2019-04-18 2019-05-24 N
Ensure medication error rates are not 5 percent or greater. Health 2019-04-18 2019-05-24 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 2019-04-18 2019-05-24 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2019-04-18 2019-05-24 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2019-04-18 2019-05-24 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2019-04-18 2019-05-24 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2019-04-16 2019-05-24 N
Conduct testing and exercise requirements. Fire Safety 2019-04-16 2019-05-24 N
Use approved construction type or materials. Fire Safety 2019-04-16 2019-05-24 N
Have corridors or aisles that are unobstructed and are at least 8 feet in width. Fire Safety 2019-04-16 2019-05-24 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2019-04-16 2019-05-24 N
Install corridor and hallway doors that block smoke. Fire Safety 2019-04-16 2019-05-24 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2019-04-16 2019-05-24 N
Have simulated fire drills held at unexpected times. Fire Safety 2019-04-16 2019-05-24 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2019-04-16 2019-05-24 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2019-04-16 2019-05-24 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2019-04-16 2019-05-24 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2019-04-16 2019-05-24 N
Have proper medical gas storage and administration areas. Fire Safety 2019-04-16 2019-05-24 N
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Health 2018-03-01 2018-04-11 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 2018-03-01 2018-04-11 N
Assure that each resident?s assessment is updated at least once every 3 months. Health 2018-03-01 2018-04-11 N
Ensure each resident receives an accurate assessment. Health 2018-03-01 2018-04-11 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2018-03-01 2018-04-11 N
Provide enough food/fluids to maintain a resident's health. Health 2018-03-01 2018-04-11 N
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Health 2018-03-01 2018-04-11 N
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2018-03-01 2018-04-11 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2018-03-01 2018-04-11 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2018-03-01 2018-04-11 N
Dispose of garbage and refuse properly. Health 2018-03-01 2018-04-11 N
Provide and implement an infection prevention and control program. Health 2018-03-01 2018-04-11 N
Provide bedrooms that don't allow residents to see each other when privacy is needed. Health 2018-03-01 2018-04-11 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2018-03-01 2018-04-11 N
Use approved construction type or materials. Fire Safety 2018-02-27 2018-04-11 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2018-02-27 2018-04-11 N
Have stairways and smokeproof enclosures used as exits that meet safety requirements. Fire Safety 2018-02-27 2018-04-11 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2018-02-27 2018-04-11 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 2018-02-27 2018-04-11 N
Provide properly protected cooking facilities. Fire Safety 2018-02-27 2018-04-11 N
Construct fire resistant interior walls. Fire Safety 2018-02-27 2018-04-11 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2018-02-27 2018-04-11 N
Install an approved automatic sprinkler system. Fire Safety 2018-02-27 2018-04-11 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2018-02-27 2018-04-11 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2018-02-27 2018-04-11 N
Install corridor and hallway doors that block smoke. Fire Safety 2018-02-27 2018-04-11 N
Meet other general requirements that are deficient. Fire Safety 2018-02-27 2018-04-11 N
Have simulated fire drills held at unexpected times. Fire Safety 2018-02-27 2018-04-11 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2018-02-27 2018-04-11 N
Have a battery powered remote alarm panel in a location accessible by operating personnel. Fire Safety 2018-02-27 2018-04-11 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2018-02-27 2018-04-11 N
Ensure proper usage of power strips and extension cords. Fire Safety 2018-02-27 2018-04-11 N
Have proper medical gas storage and administration areas. Fire Safety 2018-02-27 2018-04-11 N

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