Deficiency Records for West Pico Terrace Healthcare and Wellness Centre LP
Updated as of March 01, 2024
A list of the most recent deficiencies for West Pico Terrace Healthcare and Wellness Centre LP. 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? |
|---|---|---|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-13 | 2023-10-31 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-08-11 | 2023-09-11 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-03 | 2023-06-03 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-03-10 | 2023-04-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-10 | 2023-04-21 | Y |
| 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. | Health | 2023-03-10 | 2023-04-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-10 | 2023-04-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-03 | 2022-12-19 | Y |
| Keep all essential equipment working safely. | Health | 2022-10-24 | 2022-11-07 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-10-24 | 2022-11-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-10 | 2022-10-18 | Y |
| 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. | Health | 2022-08-23 | 2022-09-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-10 | 2022-09-10 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-02-12 | 2022-02-25 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-11-26 | 2021-12-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-26 | 2021-12-08 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-11-26 | 2021-12-08 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-05-13 | 2021-06-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-13 | 2021-06-09 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-05-13 | 2021-06-09 | N |
| 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. | Health | 2021-05-13 | 2021-06-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-13 | 2021-06-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-13 | 2021-06-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-13 | 2021-06-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-13 | 2021-06-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-13 | 2021-06-09 | N |
| 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. | Health | 2021-05-13 | 2021-06-09 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-05-13 | 2021-06-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-13 | 2021-06-09 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-13 | 2021-06-09 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-05-13 | 2021-06-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-13 | 2021-06-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-13 | 2021-06-09 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-05-13 | 2021-06-04 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-05-13 | 2021-06-04 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-05-13 | 2021-06-04 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2021-05-13 | 2021-06-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-13 | 2021-06-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-13 | 2021-06-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-13 | 2021-06-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-22 | 2021-04-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-04 | 2019-11-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-04 | 2019-11-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-10-04 | 2019-11-04 | N |
| 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. | Health | 2019-10-04 | 2019-11-04 | 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 | 2019-10-04 | 2019-11-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-04 | 2019-11-04 | N |
| Keep all essential equipment working safely. | Health | 2019-10-04 | 2019-11-04 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2019-10-04 | 2019-10-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-10-04 | 2019-10-30 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-10-04 | 2019-10-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-04 | 2019-10-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-04 | 2019-10-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-04 | 2019-10-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-04 | 2019-10-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-04 | 2019-10-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-10-13 | 2018-11-10 | N |
| 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. | Health | 2018-10-13 | 2018-11-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-13 | 2018-11-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-10-13 | 2018-11-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-10-13 | 2018-11-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-10-13 | 2018-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-13 | 2018-11-10 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-10-13 | 2018-11-10 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-10-15 | 2018-11-06 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-10-15 | 2018-11-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-10-15 | 2018-11-06 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-10-15 | 2018-11-06 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-10-15 | 2018-11-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-15 | 2018-11-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-10-15 | 2018-11-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-15 | 2018-11-06 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-10-04 | Not Fixed | N |
