Deficiency Records for Trinity Center at Luther Park
Updated as of August 01, 2018
This is not the most recent data for Trinity Center at Luther Park. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-02-20 | 2018-03-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-02-20 | 2018-03-19 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-02-20 | 2018-03-19 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-02-20 | 2018-03-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-02-20 | 2018-03-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-02-20 | 2018-03-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-02-20 | 2018-03-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-02-20 | 2018-03-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-02-20 | 2018-03-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-02-15 | 2018-03-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-15 | 2018-03-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-15 | 2018-03-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-02-15 | 2018-03-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-02-15 | 2018-03-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2017-12-07 | 2017-12-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-07 | 2017-12-08 | Y |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-10-10 | 2017-11-02 | Y |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-01-12 | 2017-02-10 | Y |
| 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 | 2017-01-12 | 2017-02-10 | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-01-12 | 2017-02-10 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2016-12-08 | 2017-02-10 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2016-12-08 | 2017-02-10 | 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 | 2016-12-08 | 2017-02-10 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-12-08 | 2017-02-10 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-12-08 | 2017-02-10 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2016-12-08 | 2017-02-10 | N |
| Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. | Health | 2016-12-08 | 2017-02-10 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-12-08 | 2017-02-10 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-12-08 | 2017-02-10 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2016-12-13 | 2017-01-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2016-12-13 | 2017-01-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2016-12-13 | 2017-01-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2016-12-13 | 2017-01-13 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2016-09-22 | 2016-10-06 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-09-22 | 2016-10-06 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-09-22 | 2016-10-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-09-22 | 2016-10-06 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-09-22 | 2016-10-06 | Y |
| 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. | Health | 2016-09-22 | 2016-10-06 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-09-22 | 2016-10-06 | Y |
| Ensure that residents are safe from serious medication errors. | Health | 2016-09-22 | 2016-09-22 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-08-02 | 2016-08-29 | Y |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2016-08-02 | 2016-08-02 | Y |
| 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 | 2016-08-02 | 2016-08-02 | Y |
| 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 | 2016-02-25 | 2016-04-04 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-02-25 | 2016-04-04 | Y |
| 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 | 2015-10-29 | 2015-12-18 | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2015-10-29 | 2015-12-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2015-10-29 | 2015-12-18 | Y |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2015-11-04 | 2015-12-10 | N |
| An approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2015-11-04 | 2015-12-10 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2015-11-04 | 2015-12-10 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2015-11-04 | 2015-12-10 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2015-11-04 | 2015-12-10 | N |
| Establish and follow a written policy that permits a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2017-03-02 | Not Fixed | Y |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-03-02 | Not Fixed | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-03-02 | Not Fixed | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-03-02 | Not Fixed | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-03-02 | Not Fixed | Y |
