Deficiency Records for Ontario Grove Healthcare and Wellness Centre, LP
Updated as of April 01, 2024
A list of the most recent deficiencies for Ontario Grove 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? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-03-30 | 2023-04-14 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2022-12-12 | 2023-01-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-12 | 2023-01-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-12 | 2023-01-03 | N |
| 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 | 2022-12-02 | 2022-12-30 | 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 | 2022-12-02 | 2022-12-30 | 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 | 2022-12-02 | 2022-12-30 | N |
| 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. | Health | 2022-12-02 | 2022-12-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-02 | 2022-12-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-02 | 2022-12-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-02 | 2022-12-30 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-12-02 | 2022-12-30 | N |
| 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. | Health | 2022-12-02 | 2022-12-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-22 | 2022-10-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-11 | 2022-08-23 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-02 | 2021-09-23 | Y |
| 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. | Health | 2021-09-02 | 2021-09-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-19 | 2021-06-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-19 | 2021-06-16 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-20 | 2019-07-03 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-05-31 | 2019-06-21 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2019-05-31 | 2019-06-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-31 | 2019-06-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-31 | 2019-06-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-31 | 2019-06-21 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-05-31 | 2019-06-21 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-05-31 | 2019-06-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-31 | 2019-06-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-31 | 2019-06-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-31 | 2019-06-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-05-31 | 2019-06-21 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-05-31 | 2019-06-21 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-07-17 | 2018-08-02 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-07-17 | 2018-08-02 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-07-17 | 2018-08-02 | 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 | 2018-07-17 | 2018-08-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-07-17 | 2018-08-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-17 | 2018-08-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-07-17 | 2018-08-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-07-17 | 2018-08-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-07-17 | 2018-08-02 | N |
| 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 | 2018-05-03 | 2018-05-31 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-05-03 | 2018-05-31 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-05-03 | 2018-05-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-03 | 2018-05-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-03 | 2018-05-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-05-03 | 2018-05-31 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-05-03 | 2018-05-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-03 | 2018-05-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-03 | 2018-05-31 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-05-03 | 2018-05-31 | 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 | 2018-05-03 | 2018-05-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-03 | 2018-05-31 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-05-03 | 2018-05-31 | N |
