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Deficiency Records for Holy Trinity Eastern Orthodox N and R Center
A list of the most recent deficiencies for Holy Trinity Eastern Orthodox N and R Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Holy Trinity Eastern Orthodox N and R Center. 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? |
|---|---|---|---|---|
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-10-18 | 2024-12-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-18 | 2024-12-09 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-10-18 | 2024-12-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-10-18 | 2024-12-09 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2024-10-18 | 2024-11-29 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-10-18 | 2024-11-29 | 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 | 2024-10-18 | 2024-11-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-10-18 | 2024-11-29 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-10-18 | 2024-11-29 | 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 | 2024-10-18 | 2024-10-25 | 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 | 2024-10-18 | 2024-10-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-10-18 | 2024-10-25 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-10-18 | 2024-10-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-10-18 | 2024-10-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-10-18 | 2024-10-23 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-09-23 | 2024-10-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-09-23 | 2024-10-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-10-18 | 2024-10-21 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-06-14 | 2023-09-25 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-08 | 2023-07-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-08 | 2023-07-31 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-06-08 | 2023-07-31 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-08 | 2023-07-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-08 | 2023-07-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-08 | 2023-07-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-03 | 2023-02-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-03 | 2023-02-20 | Y |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-08-12 | 2021-08-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-12 | 2021-08-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-12 | 2021-08-13 | N |
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