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Deficiency Records for The Birches at Trillium Woods
A list of the most recent deficiencies for The Birches at Trillium Woods. 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 The Birches at Trillium Woods. 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? |
|---|---|---|---|---|
| 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 | 2024-09-12 | 2024-10-03 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-09-12 | 2024-10-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-09-10 | 2024-09-27 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-09-10 | 2024-09-26 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-09-10 | 2024-09-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-09-10 | 2024-09-24 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-08-17 | 2023-09-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-16 | 2023-09-13 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-08-16 | 2023-09-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-16 | 2023-08-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-16 | 2023-08-18 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-06-02 | 2022-07-31 | N |
| Respond appropriately to all alleged violations. | Health | 2022-06-02 | 2022-06-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-02 | 2022-06-29 | Y |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-02 | 2022-06-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-06-02 | 2022-06-03 | N |
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