A list of the most recent deficiencies for The Terrace at Bishop's Glen. 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 care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-07 | 2022-05-29 | 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 | 2022-04-07 | 2022-05-29 | 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 | 2022-04-07 | 2022-05-29 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-09-23 | 2020-12-09 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2020-09-23 | 2020-12-09 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2020-09-23 | 2020-12-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-09-23 | 2020-12-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-09-24 | 2020-10-28 | N |
| Post nurse staffing information every day. | Health | 2020-09-24 | 2020-10-28 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-09-23 | 2020-10-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-09-23 | 2020-10-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-09-23 | 2020-10-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-16 | 2018-12-16 | N |
| Keep all essential equipment working safely. | Health | 2018-11-16 | 2018-12-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-11-14 | 2018-12-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-11-14 | 2018-12-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-11-14 | 2018-12-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-14 | 2018-12-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-11-14 | 2018-12-16 | N |
