Trinity Hospital Skilled Nursing Facility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review the facility failed to ensure that one of three residents sampled (Resident 1) did not receive unnecessary medications (any drug prescribed or taken that does not provide a clear, valid medical benefit to the person it was given to) when he was given a combination of three medications (Benadryl also known as diphenhydramine [an over-the-counter allergy medication that causes drowsiness], Haldol also known as haloperidol [a strong antipsychotic medication used to treat severe behavioral problems], and Ativan also known as lorazepam [a medication used to treat anxiety disorders and which causes drowsiness]). This failure could have resulted in negative outcomes for Resident 1 such as respiratory depression, falls, fractures, confusion and excessive drowsiness.Findings: Review of the Journal of the American Geriatrics Society (a nationally recognized professional resource for geriatric healthcare [the medical specialty that focuses on the health and care of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and nursing schedule review, the facility failed to ensure that there was a Registered Nurse (RN) on duty 8 hours every day for 7 days a week. This failure had the potential to adversely affect resident's quality of care and quality of life with regards to overall health and well-being.Findings: A review of the Payroll Based Journal (PBJ, an electronic system for facilities to submit staffing information), for Fiscal Year Quarter 2 for 2025, (January 1-March 31), indicated the facility had no RN on duty for;01/04 Saturday (SA); 01/12 (Sunday SU);02/01 (SA); 02/08 (SA); 02/15 (SA); 02/22 (SA);03/01 (SA); 03/08 (SA); 03/22 (SA); and 03/29 (SA).A review of the PBJ for Fiscal Year Quarter 4 for 2024, (July1-September 30), indicated the facility had no RN on duty for;07/01 Monday (MO); 07/03 Wednesday (WE); 07/04 Thursday (TH); 07/05 Friday (FR); 07/06 (SA); 07/07 (SU); 07/08 (MO); 07/09 Tuesday (TU); 07/12(FR); 07/14 (SU); 07/18 (TH); 07/19 (FR); 07/20 (SA); 07/21 (SU); 07/25 (TH); 07/26 (FR); 07/27 (SA); 07/28 (SU); 07/31 (WE); 08/01 (TH); 08/04 (SU); 08/09 (FR);…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain professional standards of practice to ensure food service safety for the residents of the facility when: 1. During the initial tour food preparation equipment was not sanitary. 2. Dietary staff failed to maintain clean, sanitary floors. 3. Dietary staff failed to keep foods stored away from unsanitary surfaces in the walk-in refrigerator. These failures had the potential for risk of cross contamination, to cause infection control issues, and lead to food borne illness for residents consuming food in the facility. A review of a facility document titled, Infection Control, Dietary, with an expiration date of 11/07/2025, indicated, .services are provided in a manner that minimizes the risk of hospital acquired infections to patients, staff, and visitors. The document continues, Keep work areas, surfaces.clean and orderly. and Observe safe practices in storing and serving foods. A review of a facility document titled, Cleaning List- AM Cooks, undated, indicated, the cleaning of the steam table (a table…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide adequate pharmaceutical services, including accurate dispensing, and administering of all drugs, to meet the needs of each resident for two of three Residents (Residents 1 and 8) when Diclofenac Sodium (generic name) External Gel 1% / Voltaren (brand name) External Gel 1% (Topical gel containing an active ingredient of non-steroidal anti-inflammatory drug NSAID for pain relief) was ordered, dispensed, and administered without appropriate order details including the dosage quantity as required by professional standards. This failure had the potential to endanger the health and safety of residents being administered medication without the appropriate order details including dosage amount to be dispensed.During a review of the facility's policy and procedure titled, Medication and Treatment Orders, SNF (Skilled Nursing Facility) Pharmacy, dated 7/3/25, the policy indicated, Orders for medication and treatments will be consistent with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and nursing schedule review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours a day, seven days a week. This had the potential to adversely affect all of the residents' quality of life and quality of care. Findings: A review of the Payroll Based Journal (PBJ, an electronic system for facilities to submit staffing information) for Fiscal Year Quarter 1, 10/01/24-12/21/24, indicated the facility had no RN on duty for; 10/02/24, 10/03/24, 10/04/24, 10/6/24, 10/07/24, 10/08/24, 10/13/24, 10/14/24, 10/15/24, 10/20/24, 10/21/24, 10/22/24, 10/27/24, 10/28/24, 10/29/24, 11/03/24, 11/4/24, 11/05/24, 11/10/24, 11/11/24, 11/12/24, 11/17/24, 11/18/24, 11/19/24, 11/24/24, 11/25/24, 12/01/24, 12/02/24, 12/03/24, 12/09/24,12/10/24, 12/15/24, 12/16/24, 12/17/24, 12/22/24, 12/23/24, 12/24/24, 12/29/24, 12/30/24, and 12/31/24. A review of the PBJ for Fiscal Year Quarter 2 for 2024, (01/1/24-03/31/24), indicated the facility had no RN on duty for; 01/05/24, 01/06/24, 01/07/24, 01/14/24, 01/20/24, 01/21/24, 01/27/24, 01/28/24, 02/09/24, 02/10/24,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that Minimum Data Set (MDS, a standardized assessment tool that described resident health and functional status) assessments were completed accurately for eight out of nine sampled residents, (Residents 1, 2, 3, 4, 6, 7, 8 and 9) when the MDS's incorrectly indicated that these residents were using restraints (a device that limits a resident's movement). This failure had the potential for an inaccurate picture of the resident's status. Findings: A review of the document titled, Centers for Medicare and Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/1/19, located on the CMS website: MDS 3.0 RAI Manual v1.17.1_October 2019 (cms.gov), page 20 indicated: Medicare and Medicaid participating LTC facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident's functional capacity and health status. During a review of Resident 1's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the attending Physician (AP), took an active role in the supervision of the care for 7 of 9 sampled residents (Resident 1, 3, 6, 7, 8, 9 and 10), when; 1. AP did not acknowledge, sign and date the current Active Orders (the physician's orders give the facility the legal authority to provide specific care and services to residents), for the months of June and July, 2023. 2. AP did not document a Progress Note (a note describing the Resident's current status at the time when the physician visited), in each Resident's medical record after he saw them each month. These failures had the potential for residents to not receive the appropriate level of care and services and negatively impact their ability to attain or maintain their highest practicable level of emotional and physical well-being. Findings: A review of the facility's policy titled, Attending Physician Responsibilities, SNF dated 3/29/22, indicated, The provider will verify the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and nursing schedule review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours a day, seven days a week, and have a Director of Nursing (DON) on site for 40 hours per week, to supervise the care of all of the residents. This had the potential to adversely affect all of the residents' quality of life and quality of care. Findings: A review of the Payroll Based Journal (PBJ, an electronic system for facilities to submit staffing information) for Fiscal Year Quarter 1 for 2023, (10/1/22-12/31/22), indicated the facility had no RN on duty for; 10/1/22, 10/2/22, 10/08/22, 10/09/22, 10/15/22, 10/16/22, 10/23/22, 11/12/22, 11/13/22, 11/20/22, 11/26/22, 11/27/22, 12/01/22, 12/03/22, 12/04/22, 12/09/22, 12/10/22, 12/11/22, 12/16/22, 12/18/22, 12/22/22, 12/23/22, 12/24/22, 12/25/22, 12/26/22, 12/27/22, 12/28/22, 12/29/22, and 12/31/22. A review of the PBJ for Fiscal Year Quarter 2 for 2023, (1/1/23-3/31/23) indicated the facility had no RN on duty for; 1/6/23, 1/7/23, 1/12/23, 1/14/23, 1/15/23, 1/16/23, 1/22/23, 1/27/23, 1/29/23, 2/3/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the Pharmacy Consultant's (PC) Medication Regimen Review (MRR), recommendations were acted upon (responded to), by the attending physician (AP), for eight of nine sampled residents (Resident's 1, 2, 3, 6, 7, 8, 9 and 10), when: 1. AP did not respond to MRR recommendations for Resident 1 in April, 2023. 2. AP did not respond to MRR recommendations for Resident 2 in March and April, 2023. 3. AP did not respond to MRR recommendations for Resident 2 in May, 2023. 4. AP did not respond to MRR recommendations for Resident 6 in June and July, 2023. 5. AP did not respond to MRR recommendation for Resident 7 in July, 2023. 6. AP did not respond to MRR recommendations for Resident 8 in May, 2023. 7. AP did not respond to MRR recommendations for Resident 9 in June, 2023. 8. AP did not respond to MRR recommendations for Resident 10 in June, 2023. These failures had the potential for the residents to have negative clinical outcomes and subject the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to encode a Minimum Data Set (MDS, a standardized assessment tool) and submit assessments as required for one out of two sampled residents (Resident 5), when Resident 5 passed away on 4/22/23, and a discharge MDS was not submitted to CMS (Centers for Medicare and Medicaid). This failure had the potential to result in inaccurate record keeping. Findings: A review of the facility's undated policy and procedure (P&P) titled, Electronic Transmission of the MDS, SNF indicated all MDS assessments would be completed and electronically encoded into the facility's MDS system in accordance with current OBRA (Federal) regulations governing the transmission of MDS data. A review of Resident 5's clinical records indicated Resident 5 was admitted to the facility on [DATE] with the diagnosis of dementia with behavioral disturbances (inability to remember, think, or recall information that included behaviors). Resident 5 passed away on 4/22/23. During a concurrent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide one out of nine sampled residents (Resident 4) with treatment and services that were consistent with the facility's policies and procedures (P&P), when Resident 4 developed a stage two pressure ulcer (a shallow open area of the skin with a red or pink woundbed), and a physician ordered treatment was not obtained, his responsible party was not notified, nursing had not documented on his change in condition, and he was not turned and/or repositioned every two hours. This failure had the potential for Resident 4's pressure ulcer (PU) to worsen resulting in a negative health outcome. Findings: A review of the facility's undated P&P titled, Pressure Ulcer Management, SNF indicated when a resident developed a pressure ulcer the physician would be notified no later than 24 hours after discovery of the pressure ulcer and staff would obtain an order for treatment. The P&P indicated nursing interventions that would be included in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that one of one sampled residents (Resident 10) was reassessed for safe smoking, supervised during smoking, and that his plan of care was followed. This had the potential to result in physical and psychosocial harm for Resident 10. Findings: A review of the facility's policy titled, Smoking Policy-Residents, SNF dated 3/29/22, indicated, smoking is not allowed inside the facility, this includes electronic cigarettes. The resident will be evaluated on admission to determine if he or she is a smoker. The evaluation will include the current level of tobacco consumption, method, and the desire to quit smoking. Resident 10 was admitted to the facility on [DATE] with diagnoses that included cognitive decline (difficulty with recall, and thinking), diabetes, high blood pressure, and need for assistance with personal care. During a record review of Resident 10's, Active Orders dated 5/24/23, the orders indicated Resident 10 did not have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide safe storage and labeling of resident medications and medical supplies when: 1. Over the Counter (OTC) medications were not labeled with an open date in one out of one medication cart (used to store resident medication). 2. Expired wound care supplies were stored in the treatment cart. 3. The treatment cart, located in the hallway across from the nurse's station, was left unlocked and unattended. 4. Expired laboratory supplies were stored in one of two storage rooms. 5. The medication disposal box (where discontinued medication is kept awaiting destruction), located in the nurse's station was not secure and could be easily accessed and the medications removed. These failures had the potential for unsafe medication use, and the use of medical tests and supplies which would no longer be effective, which could lead to negative clinical outcomes for the residents. Findings: 1. During a concurrent observation and interview on [DATE] at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure food safety and sanitation guidelines were followed when: 1. The deep freezer had a collapsed interior lid and ice buildup, where frozen food was stored. 2. Chipped paint with exposed rust or corrosion was on white wire shelves in the three-door reach in refrigerator, where food was stored. 3. The ventilation fans in the walk-in refrigerator, and the fans by the upper windows within the kitchen, had black debris and dust buildup. 4. The pipes under the food preparation sink next to the stove and dishwashing area, were covered with black debris and cumulative dust. 5. An open, unlabed, and undated ice cream cup was in the kitchenette designated for resident snacks. 6. Multiple areas of tile and floor covering was missing from the kitchen floor and there was dirt and debris in the corners of the floor. 7. A large area in the kitchen ceiling had an open hole, exposing the wood rafters near the dishwashing area at the exit door. These failures had the potential for the resident's to consume unsanitary food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.