A list of the most recent deficiencies for Eastview Terrace. 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? |
|---|---|---|---|---|
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-27 | 2023-11-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-27 | 2023-11-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-27 | 2023-11-14 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-10-24 | 2023-11-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-24 | 2023-11-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-24 | 2023-11-13 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-10-24 | 2023-11-13 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-10-24 | 2023-11-13 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-10-24 | 2023-11-13 | N |
| 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 | 2023-10-24 | 2023-11-13 | 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 | 2023-10-24 | 2023-11-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-24 | 2023-11-13 | 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 | 2023-10-24 | 2023-11-13 | 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 | 2023-10-24 | 2023-11-13 | 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 | 2023-10-24 | 2023-11-13 | 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 | 2023-10-24 | 2023-11-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-24 | 2023-11-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-10-24 | 2023-11-13 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-10-24 | 2023-11-13 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-15 | 2023-09-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-15 | 2023-09-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-22 | 2023-09-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-24 | 2023-09-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-10 | 2023-08-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-10 | 2023-08-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-24 | 2023-08-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-24 | 2023-08-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-06 | 2023-07-19 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-07-06 | 2023-07-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-02 | 2023-05-17 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-02 | 2023-05-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-02 | 2023-05-17 | Y |
| 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 | 2023-05-02 | 2023-05-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-22 | 2023-03-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-22 | 2023-03-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-02 | 2023-03-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-02 | 2023-03-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-21 | 2022-12-09 | Y |
| 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 | 2022-09-14 | 2022-11-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-13 | 2022-11-04 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-13 | 2022-11-04 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-09-23 | 2022-10-27 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-23 | 2022-10-14 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-09-23 | 2022-10-14 | N |
| Develop a communication plan. | Fire Safety | 2022-09-23 | 2022-10-14 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-09-23 | 2022-10-14 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-09-23 | 2022-10-14 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-09-23 | 2022-10-14 | 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 | 2022-09-23 | 2022-10-14 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-09-23 | 2022-10-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-23 | 2022-10-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-23 | 2022-10-14 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-09-14 | 2022-09-30 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-09-14 | 2022-09-30 | 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 | 2022-09-14 | 2022-09-30 | 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 | 2022-09-14 | 2022-09-30 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-09-14 | 2022-09-30 | 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 | 2022-09-14 | 2022-09-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-09-14 | 2022-09-30 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-09-14 | 2022-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-14 | 2022-09-30 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-09-14 | 2022-09-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-14 | 2022-09-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-20 | 2022-08-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-14 | 2022-04-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-01 | 2022-02-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-23 | 2022-01-10 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-12-23 | 2022-01-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-01 | 2021-12-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-01 | 2021-12-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-01 | 2021-12-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-15 | 2021-11-24 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-15 | 2021-11-24 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-11-15 | 2021-11-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-12 | 2021-08-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-12 | 2021-08-19 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-08-12 | 2021-08-19 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-04-29 | 2021-06-16 | N |
| 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 | 2021-04-29 | 2021-06-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-29 | 2021-06-16 | 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 | 2021-04-29 | 2021-06-16 | 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 | 2021-04-29 | 2021-06-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-29 | 2021-06-16 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-04-29 | 2021-06-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-04-29 | 2021-06-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-28 | 2021-06-10 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-28 | 2021-06-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-28 | 2021-06-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-05-28 | 2021-06-10 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2021-05-07 | 2021-05-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-07 | 2021-05-27 | N |
| Post nurse staffing information every day. | Health | 2021-04-29 | 2021-05-19 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-29 | 2021-05-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-29 | 2021-05-10 | N |
| Respond appropriately to all alleged violations. | Health | 2021-04-29 | 2021-05-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-31 | 2021-04-30 | Y |
