UNIVERSITY MANOR HEALTH & REHA

This section preserves official CMS inspection text matched to this facility from the current provider page source.

Inspection Report:
2024-12-05
This report is the official CMS Statement of Deficiencies (Form 2567) filed after the most recent health inspection.
Each
15
is a federal standard the facility failed to meet.
Read the full inspection report
Survey: 2024-12-05 | Tag F0569 | Resident Rights Deficiencies | Severity: D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
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Survey: 2024-12-05 | Tag F0578 | Resident Rights Deficiencies | 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.
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Survey: 2024-12-05 | Tag F0625 | Resident Rights Deficiencies | 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.
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Survey: 2024-12-05 | Tag F0644 | Resident Assessment and Care Planning Deficiencies | Severity: D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
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Survey: 2024-12-05 | Tag F0656 | Resident Assessment and Care Planning Deficiencies | Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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Survey: 2024-12-05 | Tag F0657 | Resident Assessment and Care Planning Deficiencies | 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.
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Survey: 2024-12-05 | Tag F0677 | Quality of Life and Care Deficiencies | Severity: D
Provide care and assistance to perform activities of daily living for any resident who is unable.
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Survey: 2024-12-05 | Tag F0679 | Quality of Life and Care Deficiencies | Severity: E
Provide activities to meet all resident's needs.
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Survey: 2024-12-05 | Tag F0684 | Quality of Life and Care Deficiencies | Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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Survey: 2024-12-05 | Tag F0698 | Quality of Life and Care Deficiencies | Severity: D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
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Survey: 2024-12-05 | Tag F0756 | Pharmacy Service Deficiencies | Severity: E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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Survey: 2024-12-05 | Tag F0758 | Pharmacy Service Deficiencies | 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.
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Survey: 2024-12-05 | Tag F0800 | Nutrition and Dietary Deficiencies | Severity: D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
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Survey: 2024-12-05 | Tag F0883 | Infection Control Deficiencies | Severity: D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
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Survey: 2024-12-05 | Tag F0921 | Environmental Deficiencies | Severity: E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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Survey: 2025-02-03 | Tag F0584 | Resident Rights Deficiencies | 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.
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Survey: 2025-02-03 | Tag F0600 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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Survey: 2025-01-02 | Tag F0755 | Pharmacy Service Deficiencies | Severity: E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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Survey: 2024-10-09 | Tag F0600 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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Survey: 2024-09-04 | Tag F0773 | Administration Deficiencies | Severity: D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
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Survey: 2024-09-04 | Tag F0814 | Nutrition and Dietary Deficiencies | Severity: F
Dispose of garbage and refuse properly.
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Survey: 2024-04-22 | Tag F0600 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: K
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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Survey: 2024-04-22 | Tag F0730 | Nursing and Physician Services Deficiencies | Severity: C
Observe each nurse aide's job performance and give regular training.
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Survey: 2024-04-22 | Tag F0740 | Quality of Life and Care Deficiencies | Severity: D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
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Survey: 2022-05-19 | Tag F0569 | Resident Rights Deficiencies | Severity: D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
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Survey: 2022-05-19 | Tag F0640 | Resident Assessment and Care Planning Deficiencies | Severity: B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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Survey: 2022-05-19 | Tag F0657 | Resident Assessment and Care Planning Deficiencies | 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.
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Survey: 2022-05-19 | Tag F0692 | Quality of Life and Care Deficiencies | Severity: D
Provide enough food/fluids to maintain a resident's health.
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Survey: 2022-05-19 | Tag F0757 | Pharmacy Service Deficiencies | Severity: D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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Survey: 2022-05-19 | Tag F0880 | Infection Control Deficiencies | Severity: F
Provide and implement an infection prevention and control program.
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Survey: 2023-10-12 | Tag F0686 | Quality of Life and Care Deficiencies | Severity: D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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Survey: 2023-10-12 | Tag F0880 | Infection Control Deficiencies | Severity: D
Provide and implement an infection prevention and control program.
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Survey: 2023-09-12 | Tag F0600 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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Survey: 2023-09-12 | Tag F0607 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
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Survey: 2023-09-12 | Tag F0609 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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Survey: 2023-09-12 | Tag F0689 | Quality of Life and Care Deficiencies | Severity: J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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Survey: 2023-09-12 | Tag F0949 | Administration Deficiencies | Severity: F
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
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Survey: 2023-07-18 | Tag F0921 | Environmental Deficiencies | Severity: D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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Survey: 2023-04-13 | Tag F0584 | Resident Rights Deficiencies | Severity: C
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.
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Survey: 2023-04-13 | Tag F0690 | Quality of Life and Care Deficiencies | Severity: G
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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Survey: 2023-04-13 | Tag F0812 | Nutrition and Dietary Deficiencies | Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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Survey: 2023-04-13 | Tag F0880 | Infection Control Deficiencies | Severity: F
Provide and implement an infection prevention and control program.
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Survey: 2019-04-18 | Tag F0576 | Resident Rights Deficiencies | Severity: C
Ensure residents have reasonable access to and privacy in their use of communication methods.
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Survey: 2019-04-18 | Tag F0656 | Resident Assessment and Care Planning Deficiencies | Severity: E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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Survey: 2019-04-18 | Tag F0677 | Quality of Life and Care Deficiencies | Severity: D
Provide care and assistance to perform activities of daily living for any resident who is unable.
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Survey: 2019-04-18 | Tag F0744 | Quality of Life and Care Deficiencies | Severity: D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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Survey: 2019-04-18 | Tag F0759 | Pharmacy Service Deficiencies | Severity: D
Ensure medication error rates are not 5 percent or greater.
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Survey: 2019-04-18 | Tag F0803 | Nutrition and Dietary Deficiencies | Severity: E
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.
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Survey: 2019-04-18 | Tag F0812 | Nutrition and Dietary Deficiencies | Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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Survey: 2019-04-18 | Tag F0842 | Resident Assessment and Care Planning Deficiencies | Severity: D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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Survey: 2019-04-18 | Tag F0921 | Environmental Deficiencies | Severity: F
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Source: U.S. Centers for Medicare & Medicaid Services. Data reflects the most recent available inspection.