A list of the most recent deficiencies for Trinity Community. 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? |
|---|---|---|---|---|
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-21 | 2023-09-11 | 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 | 2023-08-21 | 2023-09-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-10 | 2023-04-11 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-25 | 2022-06-20 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-04-25 | 2022-06-20 | 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 | 2022-04-25 | 2022-06-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-25 | 2022-06-20 | 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 | 2022-04-25 | 2022-06-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-25 | 2022-06-20 | 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 | 2022-04-25 | 2022-06-20 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-04-25 | 2022-06-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-25 | 2022-06-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-04-25 | 2022-06-20 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-04-20 | 2022-06-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-20 | 2022-06-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-04-20 | 2022-06-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-04-20 | 2022-06-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-20 | 2022-06-20 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-16 | 2022-03-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-03 | 2022-03-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-03 | 2022-03-29 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-02-03 | 2022-03-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-09 | 2022-01-25 | 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 | 2021-12-09 | 2022-01-25 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-02-28 | 2019-04-08 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-02-28 | 2019-04-08 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-02-28 | 2019-04-08 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2019-02-28 | 2019-04-08 | 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 | 2019-02-28 | 2019-04-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-28 | 2019-04-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-28 | 2019-04-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-02-28 | 2019-04-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-02-28 | 2019-04-08 | 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 | 2019-02-28 | 2019-04-08 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-02-28 | 2019-04-08 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-02-26 | 2019-04-08 | N |
| Use approved construction type or materials. | Fire Safety | 2019-02-26 | 2019-04-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-02-26 | 2019-04-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-26 | 2019-04-08 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2017-12-21 | 2018-02-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2017-12-21 | 2018-02-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2017-12-21 | 2018-02-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-21 | 2018-02-05 | 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 | 2017-12-21 | 2018-02-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2017-12-21 | 2018-02-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2017-12-21 | 2018-02-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2017-12-21 | 2018-02-05 | N |
| Install proper backup exit lighting. | Fire Safety | 2017-12-20 | 2018-02-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-12-20 | 2018-02-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-12-20 | 2018-02-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-12-20 | 2018-02-05 | N |
