A list of the most recent deficiencies for Trinity Manor. 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 | 2023-02-16 | 2023-03-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-16 | 2023-03-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-16 | 2023-03-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-16 | 2023-03-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-16 | 2023-03-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-16 | 2023-03-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-09 | 2023-02-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-02-09 | 2023-02-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-09 | 2023-02-28 | 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 | 2021-08-03 | 2021-08-26 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-08-03 | 2021-08-26 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-07-15 | 2021-08-24 | 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 | 2021-07-15 | 2021-08-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-07-15 | 2021-08-24 | 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 | 2021-07-15 | 2021-08-24 | 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 | 2021-07-15 | 2021-08-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-15 | 2021-08-24 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-07-15 | 2021-08-24 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-10-16 | 2019-11-15 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-10-16 | 2019-11-15 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-10-16 | 2019-11-15 | N |
| Develop a communication plan. | Fire Safety | 2019-10-16 | 2019-11-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-10-16 | 2019-11-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-10-16 | 2019-11-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-16 | 2019-11-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-16 | 2019-11-15 | 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 | 2019-10-10 | 2019-10-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-10 | 2019-10-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-10 | 2019-10-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-10-10 | 2019-10-30 | 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 | 2019-10-16 | 2019-10-16 | N |
