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Deficiency Records for University Post-Acute Rehab
A list of the most recent deficiencies for University Post-Acute Rehab. 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 Post-Acute Rehab. 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? |
|---|---|---|---|---|
| List the names and contact information of those in the facility. | Fire Safety | 2024-06-11 | 2024-06-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-06-11 | 2024-06-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-06-11 | 2024-06-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-06-11 | 2024-06-27 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-06-11 | 2024-06-27 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-06-11 | 2024-06-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-06-11 | 2024-06-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-11 | 2024-06-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-06-11 | 2024-06-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-06-11 | 2024-06-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-06-11 | 2024-06-27 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-06-11 | 2024-06-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-06-11 | 2024-06-27 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-06-11 | 2024-06-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-06-11 | 2024-06-27 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-06-11 | 2024-06-27 | 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 | 2024-06-06 | 2024-06-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-06-06 | 2024-06-26 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-06-06 | 2024-06-26 | 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 | 2024-06-06 | 2024-06-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-06 | 2024-06-26 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-31 | 2024-06-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-21 | 2024-03-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-28 | 2023-12-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-12 | 2023-01-23 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-01-27 | 2022-02-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-13 | 2022-02-11 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-01-13 | 2022-02-11 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-01-13 | 2022-02-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-01-13 | 2022-02-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-13 | 2022-02-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-13 | 2022-02-11 | 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 | 2022-01-13 | 2022-02-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-13 | 2022-02-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-13 | 2022-02-11 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-01-19 | 2022-01-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-19 | 2022-01-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-19 | 2022-01-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-19 | 2022-01-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-06 | 2019-08-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-06-06 | 2019-08-13 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-06-06 | 2019-08-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-06 | 2019-08-13 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-06-06 | 2019-08-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-06 | 2019-08-13 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-06-06 | 2019-08-13 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-06-06 | 2019-08-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-06 | 2019-08-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-06 | 2019-08-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-06-06 | 2019-08-13 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-07-29 | 2019-08-12 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-07-29 | 2019-08-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-07-29 | 2019-08-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-29 | 2019-08-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-29 | 2019-08-12 | N |
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