Deficiency Records for East Terrace Rehabilitation and Wellness Centre, LP
Updated as of March 01, 2024
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? |
|---|---|---|---|---|
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-12-01 | 2023-12-31 | 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 | 2023-12-01 | 2023-12-31 | 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 | 2023-12-01 | 2023-12-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-01 | 2023-12-31 | 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 | 2023-12-01 | 2023-12-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-01 | 2023-12-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-01 | 2023-12-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-01 | 2023-12-31 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-12-01 | 2023-12-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-01 | 2023-12-31 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-06 | 2023-12-27 | N |
| 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 | 2023-07-11 | 2023-07-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-06 | 2023-07-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-27 | 2023-07-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-01 | 2023-06-23 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-15 | 2023-05-31 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-05-15 | 2023-05-31 | 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 | 2023-05-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-12 | 2023-04-27 | Y |
| 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 | 2023-04-12 | 2023-04-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-05 | 2023-01-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-05 | 2023-01-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-10 | 2022-12-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-10 | 2022-12-10 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-11-10 | 2022-12-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-11-10 | 2022-12-10 | 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 | 2022-11-10 | 2022-12-10 | 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 | 2022-11-10 | 2022-12-10 | 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 | 2022-11-10 | 2022-12-10 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-11-10 | 2022-12-10 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-11-10 | 2022-12-10 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-11-10 | 2022-12-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-10 | 2022-12-10 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2022-11-10 | 2022-12-10 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-11-10 | 2022-12-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-10 | 2022-12-10 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-09 | 2022-12-07 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-11-09 | 2022-12-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-09 | 2022-12-07 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-11-09 | 2022-12-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-03 | 2022-12-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-19 | 2022-11-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-13 | 2022-10-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-19 | 2022-09-18 | Y |
| 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 | 2022-08-19 | 2022-09-18 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-08-19 | 2022-09-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-07 | 2022-08-12 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-06-03 | 2022-07-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-03 | 2022-07-25 | Y |
| 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 | 2022-06-03 | 2022-07-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-01 | 2022-03-31 | 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 | 2022-03-01 | 2022-03-31 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-23 | 2022-03-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-06 | 2022-02-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-02 | 2021-12-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-29 | 2021-12-10 | 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 | 2021-11-17 | 2021-12-02 | Y |
| Dispose of garbage and refuse properly. | Health | 2021-11-17 | 2021-12-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-17 | 2021-12-02 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-17 | 2021-12-02 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-10-13 | 2021-11-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-27 | 2021-11-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-27 | 2021-11-16 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-08-11 | 2021-08-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-11 | 2021-08-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-03 | 2021-08-20 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-03 | 2021-08-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-03 | 2021-08-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-03 | 2021-08-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-03 | 2021-08-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-15 | 2021-07-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-15 | 2021-07-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-19 | 2021-03-26 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-03-16 | 2021-03-24 | 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 | 2020-02-10 | 2020-03-13 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-02-10 | 2020-03-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-10 | 2020-03-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-10 | 2020-03-13 | 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 | 2020-02-10 | 2020-03-13 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-02-10 | 2020-03-13 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2020-02-10 | 2020-03-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-10 | 2020-03-13 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-02-10 | 2020-03-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-10 | 2020-03-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-10 | 2020-03-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-06 | 2020-03-03 | 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 | 2020-02-06 | 2020-03-03 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2020-02-06 | 2020-03-03 | 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 | 2020-02-06 | 2020-03-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-06 | 2020-03-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-02-06 | 2020-03-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-06 | 2020-03-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-06 | 2020-03-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-06 | 2020-03-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-06 | 2020-03-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-06 | 2020-03-03 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2020-02-06 | 2020-03-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-06 | 2020-03-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-06 | 2020-03-03 | N |
