A list of the most recent deficiencies for Trinity Care Center. 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 and implement an infection prevention and control program. | Health | 2023-03-30 | 2023-04-15 | Y |
| Have an alternate power supply for its alarm system. | Fire Safety | 2022-07-22 | 2022-08-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-22 | 2022-08-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-09 | 2022-07-01 | 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 | 2022-06-09 | 2022-07-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-09 | 2022-07-01 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-06-09 | 2022-07-01 | 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 | 2022-06-09 | 2022-07-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-09 | 2022-07-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-19 | 2022-06-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-28 | 2021-11-19 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-10-28 | 2021-11-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-28 | 2021-10-29 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-23 | 2019-11-14 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-10-22 | 2019-11-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-22 | 2019-11-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-22 | 2019-11-14 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-11-08 | 2018-12-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-11-08 | 2018-12-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-11-08 | 2018-12-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-11-08 | 2018-12-17 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2018-11-08 | 2018-12-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-11-08 | 2018-12-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-11-07 | 2018-11-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-10-22 | Not Fixed | N |
