A list of the most recent deficiencies for Trinity Village Medical Center. 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? |
|---|---|---|---|---|
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-08-25 | 2023-09-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-25 | 2023-09-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-25 | 2023-09-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-25 | 2023-09-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-25 | 2023-09-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-25 | 2023-09-24 | 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 | 2023-08-25 | 2023-09-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-25 | 2023-09-24 | N |
| Dispose of garbage and refuse properly. | Health | 2023-08-25 | 2023-09-24 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-08-25 | 2023-09-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-25 | 2023-09-24 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-08-22 | 2023-09-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-22 | 2022-12-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-22 | 2022-12-22 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-11-22 | 2022-12-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-22 | 2022-12-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-04 | 2022-12-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-04 | 2022-12-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-27 | 2022-10-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-27 | 2022-10-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-10 | 2022-07-10 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-06-10 | 2022-07-10 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-06-10 | 2022-07-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-10 | 2022-07-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-10 | 2022-07-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-10 | 2022-07-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-10 | 2022-07-10 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-06-10 | 2022-07-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-06-10 | 2022-07-10 | 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 | 2022-06-10 | 2022-07-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-06-10 | 2022-07-10 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-06-10 | 2022-07-10 | 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 | 2022-06-10 | 2022-07-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-10 | 2022-07-10 | N |
| Report COVID19 data to residents and families. | Health | 2022-06-10 | 2022-07-10 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-06-10 | 2022-07-10 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-10 | 2022-07-10 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-06-10 | 2022-06-10 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-06-10 | 2022-06-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-10 | 2021-12-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-22 | 2021-07-02 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-04-09 | 2021-04-19 | 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 | 2021-04-09 | 2021-04-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-09 | 2021-04-19 | N |
| Dispose of garbage and refuse properly. | Health | 2021-04-09 | 2021-04-19 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-04-06 | 2021-04-19 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-04-06 | 2021-04-19 | N |
