Deficiency Records for Trinity Hospital Skilled Nursing Facility
Updated as of March 01, 2024
A list of the most recent deficiencies for Trinity Hospital Skilled Nursing Facility. 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 each resident receives an accurate assessment. | Health | 2023-07-21 | 2023-09-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-21 | 2023-09-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-21 | 2023-09-01 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-07-21 | 2023-09-01 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-07-21 | 2023-09-01 | 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 | 2023-07-21 | 2023-09-01 | 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 | 2023-07-21 | 2023-09-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-21 | 2023-09-01 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-07-21 | 2023-08-25 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-07-24 | 2023-08-02 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-07-24 | 2023-08-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-07-24 | 2023-08-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-24 | 2023-08-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-24 | 2023-08-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-24 | 2023-08-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-24 | 2023-08-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-24 | 2023-08-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-01 | 2021-06-08 | Y |
| 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 | 2019-08-28 | 2019-10-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-28 | 2019-10-22 | 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 | 2019-08-28 | 2019-10-22 | N |
| Post nurse staffing information every day. | Health | 2019-08-28 | 2019-10-22 | N |
| Provide or obtain dental services for each resident. | Health | 2019-08-28 | 2019-10-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-28 | 2019-10-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-28 | 2019-10-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-28 | 2019-10-22 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-08-28 | 2019-10-22 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-09-23 | 2019-10-03 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-09-23 | 2019-10-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-23 | 2019-10-03 | N |
| Use approved construction type or materials. | Fire Safety | 2019-09-23 | 2019-10-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-23 | 2019-10-03 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-09-23 | 2019-10-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-23 | 2019-10-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-23 | 2019-10-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-23 | 2019-10-03 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-11-19 | 2018-12-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-11-19 | 2018-12-07 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2018-11-19 | 2018-12-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-11-19 | 2018-12-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-19 | 2018-12-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-11-19 | 2018-12-07 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-10-03 | 2018-10-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-03 | 2018-10-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-10-03 | 2018-10-24 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2018-10-03 | 2018-10-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-03 | 2018-10-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-10-03 | 2018-10-24 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-10-03 | 2018-10-24 | N |
