A list of the most recent deficiencies for Trellis Paradise. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-09-28 | 2023-12-28 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-09-28 | 2023-12-28 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-09-28 | 2023-12-28 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-09-28 | 2023-12-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-09-28 | 2023-12-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-28 | 2023-12-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-09-28 | 2023-12-28 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-09-28 | 2023-12-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-28 | 2023-12-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-28 | 2023-12-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-28 | 2023-12-28 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-09-29 | 2023-11-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-09-29 | 2023-11-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-29 | 2023-11-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-29 | 2023-11-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-29 | 2023-11-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-29 | 2023-11-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-29 | 2023-11-01 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-09-29 | 2023-11-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-29 | 2023-11-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-29 | 2023-11-01 | N |
| 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 | 2023-09-29 | 2023-11-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-29 | 2023-11-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-29 | 2023-11-01 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-09-29 | 2023-11-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-08-11 | 2022-09-09 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-08-11 | 2022-09-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-11 | 2022-09-09 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-08-11 | 2022-09-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-11 | 2022-09-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-10 | 2022-09-07 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-08-10 | 2022-09-07 | N |
