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 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 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-23 | 2020-02-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-23 | 2020-02-28 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2020-01-22 | 2020-02-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-22 | 2020-02-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-22 | 2020-02-26 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2020-01-22 | 2020-02-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2020-01-22 | 2020-02-14 | N |
