Deficiency Records for Chico Terrace Healthcare and Wellness Centre, LP
Updated as of April 01, 2024
A list of the most recent deficiencies for Chico 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? |
|---|---|---|---|---|
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-01-03 | 2024-01-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-21 | 2024-01-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-19 | 2023-10-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-19 | 2023-10-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-08 | 2023-08-15 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-08-08 | 2023-08-15 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-05-30 | 2023-06-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-01 | 2023-06-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-12 | 2023-02-17 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-11-02 | 2022-12-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-02 | 2022-12-02 | 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 | 2022-11-02 | 2022-12-02 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-11-02 | 2022-12-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-13 | 2022-10-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-15 | 2022-07-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-04-27 | 2022-05-26 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2022-04-27 | 2022-05-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-27 | 2022-05-26 | Y |
| 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 | 2022-04-27 | 2022-05-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-27 | 2022-05-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-17 | 2022-03-14 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-17 | 2022-03-14 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-02-17 | 2022-03-14 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-17 | 2022-03-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-24 | 2022-02-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-27 | 2022-02-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-27 | 2022-02-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-20 | 2021-10-12 | N |
| Respond appropriately to all alleged violations. | Health | 2021-09-10 | 2021-10-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-07 | 2021-10-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-01 | 2021-08-17 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-06-01 | 2021-08-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-01 | 2021-08-17 | 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 | 2021-06-01 | 2021-08-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-01 | 2021-08-17 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-06-01 | 2021-08-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-06-01 | 2021-08-17 | 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 | 2021-06-01 | 2021-08-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-01 | 2021-08-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-06-01 | 2021-08-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-01 | 2021-08-17 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-06-01 | 2021-08-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-01 | 2021-08-17 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-06-02 | 2021-07-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-02 | 2021-07-23 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-06-03 | 2021-07-21 | N |
| Use approved construction type or materials. | Fire Safety | 2021-06-03 | 2021-07-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-03 | 2021-07-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-03 | 2021-07-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-03 | 2021-07-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-03 | 2021-07-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-03 | 2021-07-21 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-05-21 | 2021-07-08 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-05-20 | 2021-07-08 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-05-13 | 2021-06-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-13 | 2021-06-29 | 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 | 2021-05-13 | 2021-06-29 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2021-05-13 | 2021-06-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-13 | 2021-06-29 | Y |
| Use approved construction type or materials. | Fire Safety | 2019-11-05 | 2019-11-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-05 | 2019-11-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-05 | 2019-11-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-05 | 2019-11-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-08-09 | 2018-09-04 | N |
| Provide activities to meet all resident's needs. | Health | 2018-08-09 | 2018-09-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-09 | 2018-09-04 | N |
| 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. | Health | 2018-08-09 | 2018-09-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-09 | 2018-09-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-09 | 2018-09-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-09 | 2018-09-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-08-09 | 2018-09-04 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-08-14 | 2018-08-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-08-14 | 2018-08-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-08-14 | 2018-08-23 | 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 | 2018-08-14 | 2018-08-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-08-14 | 2018-08-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-14 | 2018-08-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-14 | 2018-08-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-08-14 | 2018-08-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-08-14 | 2018-08-23 | N |
