Inspection visit
Inspection
Citations
17 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F926 - Establish policies, in accordance with applicable Federal, State, and
Have policies on smoking.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0374GeneralS&S Epotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
F758 - Medication Errors
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.
F761 - Labeling of Drugs and Biologicals
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.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the February 27, 2025 survey of EVERCARE AT UNIVERSITY?
This was a inspection survey of EVERCARE AT UNIVERSITY on February 27, 2025. The surveyor cited 17 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at EVERCARE AT UNIVERSITY on February 27, 2025?
Yes, 17 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement policies and procedures for flu and pneumonia vaccinations."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.