Deficiency Records for Overland Terrace Healthcare and Wellness Centre, LP
Updated as of April 01, 2024
A list of the most recent deficiencies for Overland 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-30 | 2024-02-20 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2024-01-10 | 2024-01-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-05 | 2024-01-05 | Y |
| 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. | Health | 2023-12-05 | 2024-01-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-27 | 2023-07-27 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-03 | 2023-05-26 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-05-03 | 2023-05-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-03 | 2023-05-26 | 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 | 2023-05-03 | 2023-05-26 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-03 | 2023-05-26 | 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 | 2023-05-03 | 2023-05-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-03 | 2023-05-26 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-05-03 | 2023-05-26 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-05-03 | 2023-05-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-03 | 2023-05-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-03 | 2023-05-26 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-05-03 | 2023-05-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-03 | 2023-05-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-03 | 2023-05-26 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-05-03 | 2023-05-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-03 | 2023-05-26 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2023-05-03 | 2023-05-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-03 | 2023-05-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-03 | 2023-05-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-03 | 2023-05-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-03 | 2023-05-26 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-14 | 2023-05-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-14 | 2023-05-14 | 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 | 2023-04-14 | 2023-05-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-27 | 2023-05-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-27 | 2023-05-09 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-04-27 | 2023-05-09 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-04-27 | 2023-05-09 | 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 | 2023-04-27 | 2023-05-09 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-04-27 | 2023-05-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-27 | 2023-05-09 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-04-27 | 2023-05-09 | 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 | 2023-04-27 | 2023-05-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-27 | 2023-05-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-27 | 2023-05-09 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-27 | 2023-05-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-27 | 2023-04-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-21 | 2023-04-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-08 | 2023-04-15 | 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 | 2023-01-23 | 2023-02-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-23 | 2023-02-27 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-01-23 | 2023-02-27 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-01-04 | 2023-02-27 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-01-04 | 2023-02-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-30 | 2022-11-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-30 | 2022-11-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-30 | 2022-11-13 | 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 | 2022-09-30 | 2022-11-13 | Y |
| Post nurse staffing information every day. | Health | 2022-09-30 | 2022-11-13 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-23 | 2022-10-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-03 | 2022-08-11 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-08-03 | 2022-08-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-03 | 2022-08-11 | Y |
| Provide appropriate foot care. | Health | 2022-08-03 | 2022-08-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-03 | 2022-08-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-11 | 2022-07-21 | Y |
| 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. | Health | 2022-07-11 | 2022-07-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-11 | 2022-07-21 | Y |
| 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. | Health | 2022-06-14 | 2022-06-24 | Y |
| Post nurse staffing information every day. | Health | 2022-06-14 | 2022-06-24 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-27 | 2022-04-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-27 | 2022-04-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-01 | 2022-03-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-17 | 2022-03-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-08 | 2022-02-24 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-02-08 | 2022-02-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-08 | 2022-02-24 | N |
| Report COVID19 data to residents and families. | Health | 2022-02-08 | 2022-02-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-22 | 2022-01-14 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-22 | 2022-01-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-28 | 2022-01-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-12 | 2021-11-22 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-11-11 | 2021-11-21 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-15 | 2021-11-03 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-10 | 2021-10-21 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-09-07 | 2021-09-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-11 | 2021-08-25 | 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 | 2021-08-11 | 2021-08-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-11 | 2021-08-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-11 | 2021-08-25 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-11 | 2021-08-12 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-07-11 | 2021-08-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-11 | 2021-08-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-11 | 2021-08-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-11 | 2021-08-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-11 | 2021-08-12 | Y |
| 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. | Health | 2021-07-11 | 2021-08-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-28 | 2021-07-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-25 | 2021-07-09 | Y |
| 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. | Health | 2021-06-08 | 2021-06-24 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-06-08 | 2021-06-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-01 | 2021-05-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-07 | 2021-04-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-07 | 2021-04-17 | Y |
| 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. | Health | 2019-11-09 | 2019-12-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-11-09 | 2019-12-09 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-11-09 | 2019-12-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-11-09 | 2019-12-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-09 | 2019-12-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-09 | 2019-12-09 | 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 | 2019-11-09 | 2019-12-09 | N |
| 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. | Health | 2019-11-09 | 2019-12-09 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2019-11-09 | 2019-12-09 | 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 | 2019-11-09 | 2019-12-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-09 | 2019-12-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-09 | 2019-12-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-12 | 2019-12-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-12 | 2019-12-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-12 | 2019-12-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-12 | 2019-12-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-12 | 2019-12-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-10-22 | 2018-12-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-22 | 2018-12-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-10-22 | 2018-12-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-22 | 2018-12-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-22 | 2018-12-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-22 | 2018-12-27 | N |
| 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 | 2018-10-22 | 2018-12-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-10-22 | 2018-12-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-22 | 2018-12-27 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-10-22 | 2018-12-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-11-26 | 2018-12-19 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-11-26 | 2018-12-19 | 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 | 2018-11-26 | 2018-12-19 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-11-26 | 2018-12-19 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-11-26 | 2018-12-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-26 | 2018-12-19 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-11-26 | 2018-12-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-11-26 | 2018-12-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-26 | 2018-12-19 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-11-09 | Not Fixed | N |
