A list of the most recent deficiencies for Trinity Oaks. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-26 | 2023-11-17 | Y |
| 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 | 2023-10-26 | 2023-11-17 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-10-26 | 2023-11-17 | 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 | 2023-10-26 | 2023-11-17 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-26 | 2023-11-17 | Y |
| Dispose of garbage and refuse properly. | Health | 2023-10-26 | 2023-11-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-26 | 2023-11-17 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-10-26 | 2023-11-17 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-10-26 | 2023-11-17 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-03-30 | 2022-04-11 | 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 | 2022-03-30 | 2022-04-11 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2019-09-05 | 2019-09-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-05 | 2019-09-16 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-08-01 | 2019-08-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-01 | 2019-08-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-01 | 2019-08-27 | N |
| Post nurse staffing information every day. | Health | 2019-08-01 | 2019-08-27 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-09-19 | 2018-11-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-09-19 | 2018-11-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-09-19 | 2018-11-03 | N |
