Inspection visit
Inspection
Citations
25 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0004GeneralS&S Epotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0015GeneralS&S Epotential for harm
Address subsistence needs for staff and patients.
- 0020GeneralS&S Epotential for harm
Establish policies and procedures including evacuation.
- 0025GeneralS&S Epotential for harm
Create arrangements with other facilities to receive patients.
- 0037GeneralS&S Epotential for harm
Establish staff and initial training requirements.
F711 - Physician Visits
Provide a written emergency evacuation plan.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F551 - In the case of a resident who has not been adjudged incompetent by the state
Give the resident's representative the ability to exercise the resident's rights.
- 0291GeneralS&S Epotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0521GeneralS&S Epotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F758 - Medication Errors
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.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F847 - Entering Into Binding Arbitration Agreements
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
FAQ · About this visit
Common questions about this visit
What happened during the September 29, 2023 survey of TRELLIS PARADISE?
This was a inspection survey of TRELLIS PARADISE on September 29, 2023. The surveyor cited 25 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at TRELLIS PARADISE on September 29, 2023?
Yes, 25 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and maintain an Emergency Preparedness Program (EP)."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.