East Terrace Rehabilitation & Wellness Centre, LP

In the surveyor’s words

From the most serious findings on record at East Terrace Rehabilitation & Wellness Centre, LP, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Jul 6, 2023

  Based on observation, interviews, and record reviews, the facility failed to provide supervision to smoking residents who were assessed having either a limited range of motion ([ROM] to move a joint with staff's assistance), insufficient motor skills to hold smoking paraphernalia (equipment such as cigarettes) or unable to light tobacco, during smoking time for three of 16 sampled smoking residents in the facility (Resident 1, 3 and 4). The facility failed to: 1.Ensure Resident 1, 3, and 4 were supervised while smoking in the patio, to prevent cigarettes burns and other injuries related to smoking per care plan titled The Resident is a Smoker. All three residents had the same care plan. 2. […]

• Immediate jeopardy, isolatedF684Dec 29, 2024

  Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had diagnoses including hypertension (HTN-high blood pressure), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), depression (a mental health condition that involves a prolonged low mood or loss of interest in activities), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and suicidal ideation (intrusive thoughts and preoccupation with death and dying), who was brought to the facility by the paramedics to be admitted on [DATE] at 9:50 p.m. was not left unattended, by failing to: 1. Provide Resident 1 with orientation of the facility. 2. […]

• Immediate jeopardy, isolatedF689Feb 1, 2024

  Based on interviews and record reviews, the facility failed to: 1. Verify admission inquiry (resident's facility documents seeking admission) from the transferring facility for accuracy to reflect Resident 1's wandering (going from place to place without a plan or purpose) and exit seeking behavior, and to ensure resident did not elope (when a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge) from the admitting facility on 1/25/2024, for one of three sampled residents (Resident 1). 2. […]

• Immediate jeopardy, isolatedF604Aug 11, 2021

  Based on observation, interview and record review, the facility failed to ensure one of 39 sampled resident (Resident 1), who were at high-risk for falls, was free from physical restraints (physical or mechanical device, material or equipment which restricts freedom of movement or access to one's body) when a certified nurse assistant (CNA 1) used a bedsheet to restrain Resident 1 to the wheelchair (WC) to prevent Resident 1's recurrent falls. This deficient practice resulted in the restriction of Resident 1's movement and violated Resident 1's right to be free from physical restraints, with a potential for emotional distress, humiliation, embarrassment, and injury and death when attempting to free himself from the restraint. […]

• Immediate jeopardy, isolatedF689Aug 11, 2021

  Based on interview and record review, the facility failed to prevent recurrent falls for one of 39 residents (Resident 1), by failing to: 1. Complete an incident report after each fall. 2. Complete an SBAR (Situation, Background, Assessment and Recommendation (SBAR, a communication tool) to document a change of condition after a fall. 3. Complete a post-fall risk assessment after each fall. 4. Notify the physician after each fall. 5. Notify all other staff of the fall with a post-fall huddle after each fall. 6. […]