A list of the most recent deficiencies for Trinity Terraces. 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? |
|---|---|---|---|---|
| Meet other general requirements. | Fire Safety | 2023-07-19 | 2023-09-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-19 | 2023-09-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-19 | 2023-09-12 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-07-26 | 2023-08-28 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-07-26 | 2023-08-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-07-26 | 2023-08-28 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-07-26 | 2023-08-28 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-26 | 2023-08-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-26 | 2023-08-28 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-07-26 | 2023-08-28 | 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 | 2023-07-26 | 2023-08-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-26 | 2023-08-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-26 | 2023-08-28 | 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 | 2023-07-26 | 2023-08-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-07-26 | 2023-08-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-26 | 2023-08-28 | N |
| Post nurse staffing information every day. | Health | 2023-07-26 | 2023-08-28 | 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 | 2023-07-26 | 2023-08-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-26 | 2023-08-28 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-07-26 | 2023-08-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-26 | 2023-08-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-26 | 2023-08-28 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-07-26 | 2023-08-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-07-26 | 2023-08-28 | 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 | 2023-07-26 | 2023-08-28 | N |
| Respond appropriately to all alleged violations. | Health | 2021-08-07 | 2021-09-24 | 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 | 2021-08-07 | 2021-09-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-07 | 2021-09-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-07 | 2021-09-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-07 | 2021-09-24 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-07 | 2021-09-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-07 | 2021-09-24 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2021-08-07 | 2021-09-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-07 | 2021-09-24 | Y |
| Implement a program that monitors antibiotic use. | Health | 2021-08-07 | 2021-09-24 | Y |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-08-04 | 2021-08-07 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-08-04 | 2021-08-07 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-08-04 | 2021-08-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-08-04 | 2021-08-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-04 | 2021-08-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-04 | 2021-08-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-04 | 2021-08-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-04 | 2021-08-07 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2021-08-04 | 2021-08-07 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-08-04 | 2021-08-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-04 | 2021-08-07 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-08-04 | 2021-08-07 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-08-04 | 2021-08-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-12 | 2019-12-10 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-09-11 | 2019-12-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-09-11 | 2019-12-10 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-09-11 | 2019-12-10 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-09-11 | 2019-12-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-09-11 | 2019-12-10 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-09-11 | 2019-12-10 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-09-11 | 2019-12-10 | N |
| Establish methods for sharing information. | Fire Safety | 2019-09-11 | 2019-12-10 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-09-11 | 2019-12-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-09-11 | 2019-12-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-11 | 2019-12-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-11 | 2019-12-10 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-09-11 | 2019-12-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-09-11 | 2019-12-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-11 | 2019-12-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-11 | 2019-12-10 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-09-11 | 2019-12-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-11 | 2019-12-10 | 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 | 2019-09-11 | 2019-11-13 | 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 | 2019-09-11 | 2019-11-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-11 | 2019-11-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-11 | 2019-11-13 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2019-09-11 | 2019-11-13 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-09-11 | 2019-11-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-11 | 2019-11-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-12 | 2019-10-24 | 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 | 2019-09-12 | 2019-10-24 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-09-12 | 2019-10-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-12 | 2019-10-24 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-09-12 | 2019-10-24 | N |
| Keep all essential equipment working safely. | Health | 2019-09-12 | 2019-10-24 | N |
