Deficiency Records for Trinity Center at Luther Park
Updated as of October 01, 2020
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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-29 | 2020-02-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-10-30 | 2019-11-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-30 | 2019-11-29 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-30 | 2019-11-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-30 | 2019-11-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-30 | 2019-11-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-16 | 2019-06-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-05-16 | 2019-06-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-05-16 | 2019-06-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-05-16 | 2019-06-28 | N |
| Respond appropriately to all alleged violations. | Health | 2019-05-16 | 2019-06-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-05-16 | 2019-06-28 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-05-16 | 2019-06-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-16 | 2019-06-28 | 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 | 2019-05-16 | 2019-06-28 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-05-16 | 2019-06-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-16 | 2019-06-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-16 | 2019-06-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-16 | 2019-06-28 | 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 | 2019-05-16 | 2019-06-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-05-16 | 2019-06-28 | 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 | 2019-05-16 | 2019-06-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-16 | 2019-06-28 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-05-16 | 2019-06-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-16 | 2019-06-28 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-05-21 | 2019-05-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-21 | 2019-05-30 | N |
| Have an externally vented heating system. | Fire Safety | 2019-05-21 | 2019-05-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-05-21 | 2019-05-29 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-05-21 | 2019-05-28 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-05-21 | 2019-05-28 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-05-21 | 2019-05-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-21 | 2019-05-28 | N |
| 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 |
| 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 |
| 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 | 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 |
| 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 |
