A list of the most recent deficiencies for Trinity Center at Luther Park. 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? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-09-21 | 2023-10-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-21 | 2023-10-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-05 | 2023-01-06 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-01-05 | 2023-01-06 | Y |
| 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 | 2023-01-05 | 2023-01-06 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-08-16 | 2022-10-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-16 | 2022-10-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-16 | 2022-10-08 | N |
| Provide activities to meet all resident's needs. | Health | 2022-08-16 | 2022-10-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-16 | 2022-10-08 | 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 | 2022-08-16 | 2022-10-08 | 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 | 2022-08-16 | 2022-10-08 | 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 | 2022-08-16 | 2022-10-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-16 | 2022-10-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-16 | 2022-10-08 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-08-16 | 2022-10-08 | Y |
| 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 | 2022-08-16 | 2022-10-08 | 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 | 2022-08-16 | 2022-10-08 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-08-16 | 2022-10-08 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-16 | 2022-10-08 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-08-09 | 2022-08-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-09 | 2022-08-20 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-08-09 | 2022-08-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-09 | 2022-08-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-09 | 2022-08-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-08 | 2021-04-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-08 | 2021-04-30 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-08 | 2021-04-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-08 | 2021-04-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-08 | 2021-04-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-08 | 2021-04-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-10 | 2021-04-26 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-04-05 | 2021-04-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-04-05 | 2021-04-12 | N |
