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Deficiency Records for Troy Manor
A list of the most recent deficiencies for Troy Manor. 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 Troy Manor. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-04-09 | 2024-05-20 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-04-09 | 2024-05-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-04-09 | 2024-05-20 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-04-09 | 2024-05-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-09 | 2024-05-20 | N |
| Provide activities to meet all resident's needs. | Health | 2024-04-09 | 2024-05-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-09 | 2024-05-20 | 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 | 2024-04-09 | 2024-05-20 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-04-09 | 2024-05-20 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2024-04-09 | 2024-05-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-04-09 | 2024-05-20 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-04-09 | 2024-05-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-09 | 2024-05-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-09 | 2024-05-20 | 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 | 2024-04-09 | 2024-05-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-09 | 2024-05-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-09 | 2024-05-20 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-04-09 | 2024-05-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-04-09 | 2024-05-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-04-09 | 2024-05-20 | N |
| Meet other general requirements. | Fire Safety | 2024-04-09 | 2024-05-20 | 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 | 2024-04-09 | 2024-05-20 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-04-09 | 2024-05-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-09 | 2024-05-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-04-09 | 2024-05-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-04-09 | 2024-05-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-04-09 | 2024-05-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-04-09 | 2024-05-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-04-09 | 2024-05-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-04-09 | 2024-05-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-04-09 | 2024-05-20 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-04-09 | 2024-05-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-20 | 2023-10-12 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-31 | 2023-10-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-31 | 2023-10-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-26 | 2023-05-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-20 | 2023-05-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-21 | 2022-12-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-27 | 2022-12-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-27 | 2022-12-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-27 | 2022-12-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-27 | 2022-12-16 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-10-27 | 2022-12-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-27 | 2022-10-27 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-12-27 | 2022-02-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-27 | 2021-12-27 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-10-28 | 2021-01-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-28 | 2021-01-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-10-28 | 2020-12-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-10-28 | 2020-12-10 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-10-28 | 2020-12-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-10-28 | 2020-12-10 | N |
| Respond appropriately to all alleged violations. | Health | 2020-10-28 | 2020-12-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-10-28 | 2020-12-10 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-10-28 | 2020-12-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-10-28 | 2020-12-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-28 | 2020-12-10 | 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 | 2020-10-28 | 2020-12-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-28 | 2020-12-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-10-28 | 2020-12-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-10-28 | 2020-12-10 | 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 | 2020-10-28 | 2020-12-10 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-10-28 | 2020-12-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-10-28 | 2020-12-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-10-28 | 2020-12-10 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2020-10-28 | 2020-12-10 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2020-10-28 | 2020-12-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-10-28 | 2020-12-10 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2020-10-28 | 2020-12-10 | N |
| Dispose of garbage and refuse properly. | Health | 2020-10-28 | 2020-12-10 | 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 | 2020-10-28 | 2020-12-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-28 | 2020-12-10 | 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 | 2020-10-28 | 2020-12-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-10-28 | 2020-12-10 | N |
| Use approved construction type or materials. | Fire Safety | 2020-10-28 | 2020-12-10 | 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 | 2020-10-28 | 2020-12-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-10-28 | 2020-12-10 | 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 | 2020-10-28 | 2020-12-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-10-28 | 2020-12-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-10-28 | 2020-12-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-10-28 | 2020-12-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-10-28 | 2020-12-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-10-28 | 2020-12-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-10-28 | 2020-12-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-10-28 | 2020-12-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-10-28 | 2020-12-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-10-28 | 2020-12-10 | N |
| Meet other general requirements. | Fire Safety | 2020-10-28 | 2020-12-10 | N |
| 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 | 2019-01-15 | 2019-02-26 | N |
| 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 | 2019-01-15 | 2019-02-26 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-01-15 | 2019-02-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-01-15 | 2019-02-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-01-15 | 2019-02-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-15 | 2019-02-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-01-15 | 2019-02-26 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-01-15 | 2019-02-26 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-01-15 | 2019-02-26 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-01-15 | 2019-02-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-15 | 2019-02-26 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2019-01-15 | 2019-02-26 | N |
| Use approved construction type or materials. | Fire Safety | 2019-01-15 | 2019-02-26 | 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 | 2019-01-15 | 2019-02-26 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-01-15 | 2019-02-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-01-15 | 2019-02-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-01-15 | 2019-02-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-15 | 2019-02-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-01-15 | 2019-02-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-01-15 | 2019-02-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-01-15 | 2019-02-26 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-01-15 | 2019-02-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-15 | 2019-02-26 | N |
| Meet other general requirements. | Fire Safety | 2019-01-15 | 2019-02-26 | N |
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