Trinity Center at Luther Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review the facility failed to appropriately provide consistent and thorough assessments for COVID positive residents and residents exposed to COVID, for the ordered 10 days, also failed to complete a neurological assessment for a resident with an unwitness fall for 17 of 21 residents reviewed. (Resident #11, #12, #18, #27, #32, #36, #42, #59, #68, #74, #75, #85, #91, #96, #97, #100, #118) Facility reported a census of 109 residents. Findings include:1. Review of Resident #11's admission MDS dated [DATE] revealed, resident was admitted to the facility on [DATE] to a private room. A BIMS of 15 (cognitively intact), diagnoses of coronary artery disease, deep vein thrombosis, heart failure, peripheral vascular disease, type 2 diabetes mellitus, and pleural effusion (excess fluid builds up in the space between the lungs and chest wall, restricting lung expansion, causing shortness of breath, chest pain, and cough). Resident #11 requires moderate assistance…

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, staff interview, and policy review, the facility failed to label food stored in the refrigerator, failed to properly thaw meat used for lunch meal service, and failed to discard delivery boxes. The facility reported a census of 109 residents.Findings include: On 12/15/25 at 8:35 AM, the following items were observed during kitchen tour:1) One (1) pack of frozen ham thawing in an aluminum pan full of standing water in the sink.2) Seven (7) packs of thawed ham in an aluminum pan of standing hot water.3) Three (3) flattened delivery boxes lying on a kettle (large machine used for making soups, etc)4) An unlabeled, clear, plastic container with sliced, white, oval items.5) An unlabeled, clear, plastic container with sliced, light green, disk shaped items.6) A unit refrigerator with a multicolored, cloth item with a resident label later identified as a coldpak. At 9:10 AM, Staff A, Registered Nurse (RN) stated she did not know who placed the item in the refrigerator. The Certified Dietary Manager (CDM) informed the unit nurse that resident healthcare items cannot be…

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 record review, staff interviews, and policy review the facility failed to ensure staff documented the non-pharmacological interventions attempted prior to the administration of anti-anxiety medication for one of five residents reviewed for unnecessary medications (Resident #39). The facility reported a census of 109 residents.Findings include:A significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, dementia and anxiety. The MDS revealed the resident had impaired short-term and long-term memory and severely impaired cognitive skills for daily decision making. The MDS also indicated the resident had inattention and disorganized thinking present, and rejected care 4-6 days during the look-back period. The MDS indicated the resident took an antipsychotic medication. The Care Plan revised 2/25/25 revealed the resident required use of an antipsychotic medication due to behaviors of anxiety and aggression…

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 clinical record review, staff interviews, and policy review, the facility failed to notify the resident's representative in writing of a transfer to the hospital and a policy for bed hold including reserve bed payment for 1 of 3 residents reviewed for hospitalization (Resident #3). The facility reported a census of 109 residents.Findings include: The Minimum Data Set (MDS) for Resident #3 dated 11/01/25 indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 05 out of 15 which indicated severely impaired cognition. It included diagnoses of kidney failure, non-Alzheimer's dementia, Alzheimer's disease, a hip fracture, and traumatic brain injury. It revealed the resident required setup assistance with eating, maximal assistance with toileting, toilet transfers, dressing, and personal hygiene, and was independent with oral hygiene and all other forms of mobility. The Care Plan revised 9/24/24 included impaired cognitive function/impaired thought processes related to unspecified dementia with confusion and directed staff to discuss concerns about…

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 direct observation, clinical record review, staff interview, policy review and Resident Assessment Instrument (RAI) Manual the facility failed to ensure proper Minimum Data Set (MDS) coding by coding residents as having physical restraints when they did not have physical restraints present, and by not coding a residents mental illness when indicated for three of twenty-two residents reviewed for MDS assessments (Resident #4, #9, and #21). The facility reported a census of 109 residents. The Minimum Data Set (MDS) assessment for Resident's #9 and #21, last completed on 09/06/2025 for Resident #9, and 09/20/2025 for Resident #21, indicate both residents had a physical restraint in the form of a bed rail present, as denoted in question P0100. The care plan for Resident #9, last updated 11/28/2025, documented the resident prefers to have side rails on their bed as it makes them feel safer. The care plan for Resident #21, last revised 12/03/2025, documented the resident prefers to have bed rails on their bed…

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, record review, staff interview, and policy review, the facility failed to use a gait belt while transferring a resident who required assistance with mobility for 1 of 22 residents (#103). The facility reported a census of 109 residents.Findings include: On 12/16/25 at 1:23 PM, Staff I, Certified Nurse Aide (CNA) was observed watching a visitor attempt to transfer Resident #103 without assistance. When the resident began losing balance, Staff I assisted the visitor with transferring the resident from a recliner to his wheelchair without using the gait belt wrapped around her waist. On 12/16/25 at 1:52 PM, J, CNA stated gait belts should be used to transfer residents who are off balance, can't stand by themselves, or for safety issues. She stated staff uses a gait belt for Resident #103 except when his friend comes. His friend gets him out of the chair himself. On 12/16/25 at 2:01 PM, Staff K, Registered Nurse (RN) stated the resident walks by himself but gets up with assistance. She stated a gait belt should be used with residents who require assistance. On…

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 record review, policy review, and staff interviews the facility failed to complete a discharge summary and discharge plan for 1 resident (#113). The facility reported a census of 111 residents. Findings include: The Electronic Health Record (EHR) revealed Resident #113 was admitted to the facility on [DATE] for skilled services. The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #113 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated completely intact cognition. The EHR included diagnoses of vertebral fractures (fractured back bones). It also documented she was independent with eating, required supervision with oral hygiene, and required maximum assistance with all other Activities of Daily Living (ADLs) except upper body dressing. The EHR lacked discharge plan and discharge summary documentation. On 10/31/24 at 8:33 AM, the administrator stated the discharge plan and discharge summary were not completed due to the circumstances surrounding 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 observation, staff interviews and policy review, the facility failed to ensure staff used proper food handling procedures to prevent possible contamination of food during lunch service with food uncovered. The facility reported a census of 111 residents. Findings include: During an observation 10/30/24 at 12:15 PM, the steam table was transported from unit B1 to unit C1 with the sweet potatoes and peas uncovered and with the bread partially uncovered. This steam table was transported from the dining room in unit B1, down a resident hallway, out into the main area and then into unit C1, down resident hallway in unit C1 and into the dining room in unit C1. Meals were then served to residents in unit C1 from the steam table. During an interview 10/30/24 at 12:50 PM, the Certified Dietary Manager (CDM), stated food should be covered during transportation in the hallways and in main areas, for infection control purposes. The CDM stated an expectation food is covered during transportation. During an interview 10/30/24 at 4:30 PM, the Administrator acknowledged an expectation 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.

Based on observations, staff interview, clinical record review and policy review the facility failed to provide appropriate catheter and peri-care for 1 of 1 resident (#103) to prevent a urinary tract infection. The facility reported a census of 111 residents. Findings include: On 10/29/24 at 1:45 pm, Resident #103 stated he had a urine bag (indwelling catheter) but could not remember if he had taken an antibiotic. The Minimum Data Set (MDS) assessment for Resident #103 dated 8/06/24 revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated moderately impaired cognition. It included diagnoses of Transient Ischemic Attack (TIA- a brief blockage of blood flow to the brain that causes stroke-like symptoms), Cerebral Infarction (stroke caused by blocked blood flow to the brain), Chronic Obstructive Pulmonary Disease (COPD), and a history of Urinary Tract Infections (UTIs). The MDS indicated Resident #103 was independent with eating, required setup assistance with oral hygiene, and required moderate assistance with toileting hygiene, bathing, sit-to-stand…

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 record review, resident and staff interview, and policy review the facility failed to complete an incident report and notify the physician and resident's emergency contact/next of kin for a new bruise for 1 (Resident #1) of 3 residents reviewed. The facility reported a census of 115 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment for Resident #1 dated 6/28/24, included diagnoses of Parkinson's (condition that deteriorates the brain) and Non-Alzheimer's. The MDS identified the resident was dependent on staff for toileting, dressing, and personal hygiene and had a Brief Interview for Mental Status score of 12, which indicated mild cognitive impairment for decision making. Interview on 8/14/24 at 10:45 AM, the resident stated she had a bruise on her upper right arm that is getting better; that she had woke up one morning and found the bruise. The resident stated she reported it to staff and was not sure what caused the bruise. Resident's progress notes documented on 6/28/24 at 9:12 PM - New skin issue of bruise on right upper arm, 3.5 centimeters…

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 record review, staff interview, and policy review the facility failed to conduct a thorough investigation of an alleged violation of abuse by a resident, by not interviewing staff regarding the allegation for one (Resident #5) of three residents reviewed. The facility reported a census of 115 residents. Findings included: The Five Day Minimum Data Set (MDS) assessment for Resident #5 dated 1/14/24, included diagnoses of Non-Alzheimer's Dementia, Anxiety Disorder, and depression. The MDS indicated the resident had a Brief Interview for Mental Status score of 14, which indicated no cognitive impairment for decision making. Review of resident's progress note dated 3/7/24 at 3:10 PM documented: This nurse brought resident to the bathroom and saw a bruise located on resident's right cheek. Resident became tearful and stated, I got the shit beat out of me. Resident then finished using the bathroom and this nurse brought resident to the Assistant Director of Nursing (ADON) for further investigation. This nurse sat in the office with ADON while investigating. Resident appeared to…

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.