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🔎 University Place Health Center And Assisted Living

Inspection Results


Inspection Overview

University Place Health Center And Assisted Living has been cited for a total of 48 deficiencies since we began saving each survey.

In Indiana, the average facility has **42.94 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2024-11-25
Correction Date: 2025-02-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Survey Date: 2024-11-25
Correction Date: 2025-02-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2024-11-25
Correction Date: 2025-02-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2024-11-25
Correction Date: 2025-02-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2024-11-25
Correction Date: 2025-02-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2024-11-25
Correction Date: 2025-02-10
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2024-11-25
Correction Date: 2025-02-10
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2023-12-01
Correction Date: 2024-01-30
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Survey Date: 2023-12-01
Correction Date: 2024-01-30
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2023-12-01
Correction Date: 2024-01-30
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2023-12-01
Correction Date: 2024-01-30
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2023-12-01
Correction Date: 2024-01-30
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: C

Post nurse staffing information every day.

Survey Date: 2023-12-01
Correction Date: 2024-01-30
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2023-12-01
Correction Date: 2024-01-30
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2023-12-01
Correction Date: 2024-01-30
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2023-12-01
Correction Date: 2024-01-30
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2022-10-25
Correction Date: 2022-11-20
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Protect each resident from the wrongful use of the resident's belongings or money.

Survey Date: 2022-10-25
Correction Date: 2022-11-20
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that residents are fully informed and understand their health status, care and treatments.

Survey Date: 2022-10-25
Correction Date: 2022-11-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Survey Date: 2022-10-25
Correction Date: 2022-11-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2022-10-25
Correction Date: 2022-11-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2022-10-25
Correction Date: 2022-11-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2022-10-25
Correction Date: 2022-11-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: B

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2021-03-29
Correction Date: 2021-04-28
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-03-29
Correction Date: 2021-04-28
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2021-02-11
Correction Date: 2021-03-16
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-10-15
Correction Date: 2020-11-09
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2019-08-22
Correction Date: 2019-09-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2019-08-22
Correction Date: 2019-09-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2019-08-22
Correction Date: 2019-09-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2019-08-22
Correction Date: 2019-09-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2019-08-22
Correction Date: 2019-09-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Survey Date: 2019-08-22
Correction Date: 2019-09-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2019-08-22
Correction Date: 2019-09-21
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2019-08-22
Correction Date: 2019-09-21
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2019-08-22
Correction Date: 2019-09-21
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Survey Date: 2019-08-22
Correction Date: 2019-09-21
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2018-07-02
Correction Date: 2018-08-01
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2018-07-02
Correction Date: 2018-08-01
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Survey Date: 2018-07-02
Correction Date: 2018-08-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2018-07-02
Correction Date: 2018-08-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2018-07-02
Correction Date: 2018-08-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2018-07-02
Correction Date: 2018-08-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2018-07-02
Correction Date: 2018-08-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2018-07-02
Correction Date: 2018-08-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.

Survey Date: 2018-07-02
Correction Date: 2018-08-01
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2018-07-02
Correction Date: 2018-08-01
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2018-07-02
Correction Date: 2018-08-01
Category: Infection Control Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**