Deficiency Records for East Terrace Rehabilitation and Wellness Centre, LP
Updated as of May 01, 2019
This is not the most recent data for East Terrace Rehabilitation and Wellness Centre, LP. For the most recent information, click here.
A list of the most recent deficiencies for East Terrace Rehabilitation 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-02-09 | 2019-03-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-09 | 2019-03-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-02-09 | 2019-03-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-09 | 2019-03-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-02-09 | 2019-03-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-02-09 | 2019-03-08 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-02-09 | 2019-03-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-09 | 2019-03-08 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Establish methods for sharing information. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-02-09 | 2019-03-05 | 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 | 2019-02-09 | 2019-03-05 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Meet other general requirements. | Fire Safety | 2019-02-09 | 2019-03-05 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-09-23 | 2018-09-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-01-13 | 2018-02-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-01-13 | 2018-02-09 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2018-01-13 | 2018-02-09 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-01-13 | 2018-02-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-01-13 | 2018-02-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-01-13 | 2018-02-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-01-13 | 2018-02-09 | 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 | 2018-01-13 | 2018-02-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-01-13 | 2018-02-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-01-13 | 2018-02-09 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-01-17 | 2018-02-07 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-01-17 | 2018-02-07 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-01-17 | 2018-02-07 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-01-17 | 2018-02-07 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-01-17 | 2018-02-07 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-01-17 | 2018-02-07 | N |
| Meet other general requirements. | Fire Safety | 2018-01-17 | 2018-02-07 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-01-17 | 2018-02-07 | 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 | 2018-01-17 | 2018-02-07 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-01-17 | 2018-02-07 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-01-17 | 2018-02-07 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-01-17 | 2018-02-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-01-17 | 2018-02-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-01-17 | 2018-02-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-01-17 | 2018-02-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-01-17 | 2018-02-07 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2018-01-17 | 2018-02-07 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-01-17 | 2018-02-07 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2018-01-17 | 2018-02-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-01-02 | 2018-01-05 | Y |
| Provide written records when a resident is transferred or discharged. | Health | 2017-11-21 | 2017-12-15 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-11-21 | 2017-12-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-11-20 | 2017-12-07 | Y |
| Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers. | Health | 2017-01-19 | 2017-03-15 | Y |
| 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 | 2017-01-11 | 2017-02-01 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-01-11 | 2017-02-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-01-11 | 2017-02-01 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2017-01-11 | 2017-02-01 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-01-11 | 2017-02-01 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-01-11 | 2017-02-01 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2016-12-13 | 2017-01-30 | Y |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2016-12-16 | 2016-12-16 | Y |
