A list of the most recent deficiencies for Trinity Regional Rehab 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-05-04 | 2023-06-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-04 | 2023-06-26 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-04 | 2023-06-26 | Y |
| 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 | 2023-05-04 | 2023-06-26 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-04 | 2023-06-26 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-09-23 | 2022-10-11 | N |
| 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 | 2022-09-21 | 2022-10-10 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-04-22 | 2021-05-22 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-04-22 | 2021-05-22 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-04-22 | 2021-05-22 | 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 | 2021-04-22 | 2021-05-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-22 | 2021-05-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-22 | 2021-05-22 | 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 | 2021-04-22 | 2021-05-22 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-04-22 | 2021-05-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-22 | 2021-05-22 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-04-20 | 2021-05-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-20 | 2021-05-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-03 | 2019-06-03 | 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 | 2019-05-03 | 2019-06-03 | 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 | 2019-05-03 | 2019-06-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-03 | 2019-06-03 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-04-30 | 2019-06-03 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-04-30 | 2019-06-03 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-04-30 | 2019-06-03 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-04-30 | 2019-06-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-04-30 | 2019-06-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-04-30 | 2019-06-03 | N |
