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Deficiency Records for The Laurels of University Park
A list of the most recent deficiencies for The Laurels of University Park. 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 The Laurels of University Park. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-21 | 2023-04-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-21 | 2023-04-17 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-30 | 2022-11-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-30 | 2022-11-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-09-30 | 2022-11-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-30 | 2022-11-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-15 | 2022-07-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-06-15 | 2022-07-26 | N |
| 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 | 2022-06-15 | 2022-07-26 | 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 | 2022-06-15 | 2022-07-26 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-06-15 | 2022-07-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-15 | 2022-07-26 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-06-15 | 2022-07-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-15 | 2022-07-26 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-06-15 | 2022-07-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-15 | 2022-07-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-15 | 2022-07-26 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-06-15 | 2022-07-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-15 | 2022-07-26 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-06-15 | 2022-07-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-15 | 2022-07-26 | 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 | 2022-06-15 | 2022-07-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-15 | 2022-07-26 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-06-15 | 2022-07-26 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-15 | 2022-07-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-15 | 2022-07-26 | 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 | 2022-06-15 | 2022-07-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-15 | 2022-07-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-15 | 2022-07-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-15 | 2022-07-26 | 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 | 2022-06-15 | 2022-07-26 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-05-21 | 2021-07-13 | 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 | 2021-05-21 | 2021-07-13 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2021-05-21 | 2021-07-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-21 | 2021-07-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-21 | 2021-07-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-21 | 2021-07-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-05-21 | 2021-07-13 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-05-21 | 2021-07-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-21 | 2021-07-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-05-21 | 2021-07-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-21 | 2021-07-13 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-05-12 | 2021-06-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-05-12 | 2021-06-15 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-05-12 | 2021-06-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-05-12 | 2021-06-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-12 | 2021-06-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-12 | 2021-06-15 | 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 | 2021-05-12 | 2021-06-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-12 | 2021-06-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-12 | 2021-06-15 | 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 | 2021-05-12 | 2021-06-15 | 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 | 2021-05-12 | 2021-06-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-12 | 2021-06-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-05-12 | 2021-06-15 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-05-12 | 2021-06-15 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-05-12 | 2021-06-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-12 | 2021-06-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-12 | 2021-06-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-12 | 2021-06-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-07 | 2019-10-11 | N |
| 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 | 2019-08-07 | 2019-09-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-08-07 | 2019-09-20 | 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 | 2019-08-07 | 2019-09-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-08-07 | 2019-09-20 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2019-08-07 | 2019-09-20 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-08-07 | 2019-09-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-07 | 2019-09-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-07 | 2019-09-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-07 | 2019-09-20 | 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 | 2019-08-07 | 2019-09-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-07 | 2019-09-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-07 | 2019-09-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-07 | 2019-09-20 | N |
| Provide appropriate foot care. | Health | 2019-08-07 | 2019-09-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-07 | 2019-09-20 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-08-07 | 2019-09-20 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-08-07 | 2019-09-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-07 | 2019-09-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-08-07 | 2019-09-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-08-07 | 2019-09-20 | 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 | 2019-08-07 | 2019-09-20 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-08-07 | 2019-09-20 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-08-07 | 2019-09-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-07 | 2019-09-20 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2019-08-07 | 2019-09-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-08-07 | 2019-09-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-08-07 | 2019-09-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-08-08 | 2019-08-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-07 | 2019-07-11 | N |
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