A list of the most recent deficiencies for Trinity Hill Care 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-28 | 2023-09-21 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-05-22 | 2023-07-03 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-05-22 | 2023-07-03 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-04-14 | 2022-05-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-14 | 2022-05-26 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-04-14 | 2022-05-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-14 | 2022-05-26 | Y |
| 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 | 2022-04-14 | 2022-05-26 | Y |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-03-09 | 2022-03-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-03-09 | 2022-03-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-09 | 2022-03-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-13 | 2022-03-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-13 | 2022-03-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-27 | 2021-10-28 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-06-17 | 2021-09-23 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-02-05 | 2019-03-29 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-01-09 | 2019-02-20 | 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 | 2019-01-09 | 2019-02-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-01-09 | 2019-02-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-01-09 | 2019-02-20 | N |
| Respond appropriately to all alleged violations. | Health | 2019-01-09 | 2019-02-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-01-09 | 2019-02-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-09 | 2019-02-20 | N |
| 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 | 2019-01-09 | 2019-02-20 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-01-09 | 2019-02-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-09 | 2019-02-20 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-11-02 | 2017-12-14 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-11-02 | 2017-12-14 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-11-02 | 2017-12-14 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-11-02 | 2017-12-14 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-11-02 | 2017-12-14 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-11-02 | 2017-12-14 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-11-01 | 2017-12-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-11-01 | 2017-12-13 | N |
