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🔎 University City Rehabilitation And Healthcare Ctr

Inspection Results


Inspection Overview

University City Rehabilitation And Healthcare Ctr has been cited for a total of 112 deficiencies since we began saving each survey.

In Pennsylvania, the average facility has **42.85 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 safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2025-03-25
Correction Date: 2025-04-10
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Allow residents to self-administer drugs if determined clinically appropriate.

Survey Date: 2025-01-27
Correction Date: 2025-03-05
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2025-01-27
Correction Date: 2025-03-05
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2025-01-27
Correction Date: 2025-03-05
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2025-01-27
Correction Date: 2025-03-05
Category: Resident Rights 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: 2025-01-27
Correction Date: 2025-03-05
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Survey Date: 2025-01-27
Correction Date: 2025-03-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2025-01-27
Correction Date: 2025-03-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Survey Date: 2025-01-27
Correction Date: 2025-03-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2025-01-27
Correction Date: 2025-03-05
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: 2025-01-27
Correction Date: 2025-03-05
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2025-01-27
Correction Date: 2025-03-05
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2025-01-27
Correction Date: 2025-03-05
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Make sure that a working call system is available in each resident's bathroom and bathing area.

Survey Date: 2025-01-27
Correction Date: 2025-03-05
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2024-12-09
Correction Date: 2025-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2024-12-09
Correction Date: 2025-01-06
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: B

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2024-09-16
Correction Date: 2024-09-30
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Allow residents to self-administer drugs if determined clinically appropriate.

Survey Date: 2024-04-24
Correction Date: 2024-05-29
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2024-04-24
Correction Date: 2024-05-29
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Survey Date: 2024-04-24
Correction Date: 2024-05-29
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: 2024-04-24
Correction Date: 2024-05-29
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Survey Date: 2024-04-24
Correction Date: 2024-05-29
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2024-04-24
Correction Date: 2024-05-29
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2024-04-24
Correction Date: 2024-05-29
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Survey Date: 2024-04-24
Correction Date: 2024-05-29
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2024-04-24
Correction Date: 2024-05-29
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2024-04-24
Correction Date: 2024-05-29
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Make sure that a working call system is available in each resident's bathroom and bathing area.

Survey Date: 2024-04-24
Correction Date: 2024-05-29
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Survey Date: 2024-03-05
Correction Date: 2024-03-27
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2024-02-09
Correction Date: 2024-03-13
Category: Pharmacy Service Deficiencies
From Complaint: Y

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: 2024-02-09
Correction Date: 2024-03-13
Category: Pharmacy Service 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: 2024-01-10
Correction Date: 2024-01-31
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Survey Date: 2024-01-10
Correction Date: 2024-01-31
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2023-12-26
Correction Date: 2024-01-24
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2023-12-26
Correction Date: 2024-01-24
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Survey Date: 2023-08-09
Correction Date: 2023-09-10
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2023-06-16
Correction Date: 2023-09-10
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Assure that each resident’s assessment is updated at least once every 3 months.

Survey Date: 2023-06-16
Correction Date: 2023-09-10
Category: Resident Assessment and Care Planning 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: 2023-06-16
Correction Date: 2023-09-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2023-06-16
Correction Date: 2023-09-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Survey Date: 2023-06-16
Correction Date: 2023-09-10
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: 2023-06-16
Correction Date: 2023-09-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2023-06-16
Correction Date: 2023-09-10
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide timely, quality laboratory services/tests to meet the needs of residents.

Survey Date: 2023-06-16
Correction Date: 2023-09-10
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Survey Date: 2023-06-16
Correction Date: 2023-09-10
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Survey Date: 2023-06-16
Correction Date: 2023-09-10
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: G

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

Survey Date: 2023-04-24
Correction Date: 2023-05-11
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2022-09-28
Correction Date: 2022-11-07
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2022-09-28
Correction Date: 2022-11-07
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Survey Date: 2022-09-28
Correction Date: 2022-11-07
Category: Quality of Life and Care 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: 2022-09-28
Correction Date: 2022-11-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2022-09-28
Correction Date: 2022-11-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Survey Date: 2022-09-28
Correction Date: 2022-11-07
Category: Quality of Life and Care 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: 2022-09-28
Correction Date: 2022-11-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Survey Date: 2022-09-28
Correction Date: 2022-11-07
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: 2022-09-28
Correction Date: 2022-11-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2022-09-28
Correction Date: 2022-11-07
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide routine and 24-hour emergency dental care for each resident.

Survey Date: 2022-09-28
Correction Date: 2022-11-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2022-09-28
Correction Date: 2022-11-07
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Survey Date: 2022-09-28
Correction Date: 2022-11-07
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2022-09-28
Correction Date: 2022-11-07
Category: Resident Assessment and Care Planning 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: 2022-07-08
Correction Date: 2022-07-25
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Provide routine and 24-hour emergency dental care for each resident.

Survey Date: 2022-01-03
Correction Date: 2022-02-01
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2021-07-07
Correction Date: 2021-09-01
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-07-07
Correction Date: 2021-09-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-07-07
Correction Date: 2021-09-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives an accurate assessment.

Survey Date: 2021-07-07
Correction Date: 2021-09-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2021-07-07
Correction Date: 2021-09-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Survey Date: 2021-07-07
Correction Date: 2021-09-01
Category: Resident Assessment and Care Planning 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: 2021-07-07
Correction Date: 2021-09-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-07-07
Correction Date: 2021-09-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: K

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

Survey Date: 2021-07-07
Correction Date: 2021-09-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

Provide safe, appropriate pain management for a resident who requires such services.

Survey Date: 2021-07-07
Correction Date: 2021-09-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2021-07-07
Correction Date: 2021-09-01
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

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: 2021-07-07
Correction Date: 2021-09-01
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: 2021-07-07
Correction Date: 2021-09-01
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Survey Date: 2021-07-07
Correction Date: 2021-09-01
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2021-07-07
Correction Date: 2021-09-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Survey Date: 2021-07-07
Correction Date: 2021-09-01
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Survey Date: 2021-07-07
Correction Date: 2021-09-01
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2021-07-07
Correction Date: 2021-09-01
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2021-02-24
Correction Date: 2021-03-18
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2021-02-24
Correction Date: 2021-03-18
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2021-02-24
Correction Date: 2021-03-18
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2021-02-24
Correction Date: 2021-03-18
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-02-24
Correction Date: 2021-03-18
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2020-09-03
Correction Date: 2020-09-24
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2020-09-03
Correction Date: 2020-09-22
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2020-07-14
Correction Date: 2020-07-27
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2019-05-29
Correction Date: 2019-07-24
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-05-29
Correction Date: 2019-07-24
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2019-05-29
Correction Date: 2019-07-24
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: F

The resident has the right to receive notices in a format and a language he or she understands.

Survey Date: 2019-05-29
Correction Date: 2019-07-24
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: 2019-05-29
Correction Date: 2019-07-24
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2019-05-29
Correction Date: 2019-07-24
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-05-29
Correction Date: 2019-07-24
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2019-05-29
Correction Date: 2019-07-24
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: 2019-05-29
Correction Date: 2019-07-24
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Plan the resident's discharge to meet the resident's goals and needs.

Survey Date: 2019-05-29
Correction Date: 2019-07-24
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Survey Date: 2019-05-29
Correction Date: 2019-07-24
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: 2019-05-29
Correction Date: 2019-07-24
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

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

Survey Date: 2019-05-29
Correction Date: 2019-07-24
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: 2019-05-29
Correction Date: 2019-07-24
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: 2019-05-29
Correction Date: 2019-07-24
Category: Quality of Life and Care 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: 2019-05-29
Correction Date: 2019-07-24
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Survey Date: 2019-05-29
Correction Date: 2019-07-24
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2019-05-29
Correction Date: 2019-07-24
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Survey Date: 2019-05-29
Correction Date: 2019-07-24
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2019-05-29
Correction Date: 2019-07-24
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Dispose of garbage and refuse properly.

Survey Date: 2019-05-29
Correction Date: 2019-07-24
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2019-05-29
Correction Date: 2019-07-24
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Make sure that a working call system is available in each resident's bathroom and bathing area.

Survey Date: 2019-05-29
Correction Date: 2019-07-24
Category: Environmental 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.**