Trinity Manor

The facility had a census of 40 residents. Based on observation, interview, and record review the facility failed to store, prepare, and serve food in a sanitary manner for the 40 residents who received meals from the facility kitchen. Findings included: - On 01/21/25 at 07:48 AM, observation in the facility kitchen revealed: A refrigerator with an opened, partially used, undated plastic quart container of macaroni salad, undated, opened, and partially used bags of diced ham, and pre-cooked chicken pieces. The walk-in freezer had three boxes of food stored on the floor. On 01/22/25 at 10:45 AM, observation in the facility kitchen revealed the utensil drawers below the coffee maker had a piece of wrinkled paper towel, a brownish drip in a teaspoon, and a small amount of dried food particles. The drawers under a make table had plastic bins for scoops and ladles with dried food and spills in the bins. The walk-in freezer stall had two boxes of food on the floor. The kitchen had one of six fluorescent light covers with a large number of cracks. On 01/21/25 at 07:48 AM, Dietary Staff…

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.

The facility had a census of 40 residents. Based on observation, record review and interview, the facility failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as air-conditioning units in large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by legionella) which placed the residents at risk of contracting infectious processes. Findings included: - On 01/22/25 at 04:50 PM, Administrative Staff A reported the facility lacked a waterborne pathogen/Legionella program. The facility's Legionella Water Management Program dated 08/2023, documented as part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. The purpose of the water management program is used to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionella disease. The facility failed to implement…

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 The facility had a census of 40 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure two of five residents reviewed during the medication administration pass remained free of medication errors for Resident (R) 19 and R21. This placed the residents at risk for adverse reactions from the medication. Findings included: - R19's Electronic Health Record (EHR) revealed diagnoses of dysphagia (swallowing difficulty), irritable bowel syndrome (IBS- abnormally increased motility of the small and large intestines), and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R19's Annual Minimum Data Set (MDS), dated [DATE], recorded R19 had a Brief Interview for Mental Status score of 00 that indicated she had severely impaired cognition. The MDS recorded she required extensive assistance of two staff with activities of daily living (ADLs). R19's Care Plan, dated 12/31/24,…

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.

The facility reported a census of 43 residents. Based on observation, interview, and record review, the facility failed to provide sanitary food storage to prevent the spread of food borne illness to the residents of the facility. Findings included: - On 02/07/03 at 07:52 AM initial tour of the kitchen with Dietary Staff CC revealed the following concerns: In the main refrigerator: 1. A large bag of shredded cheese, open and undated. 2. A container of sliced tomatoes, lacked preparation or expiration date. 3. A large bag of shredded lettuce, open and undated. 4. A small bag of shredded lettuce, open and undated. On 02/08/23 at 12:15 PM, Dietary Staff BB, stated staff should label food products in the refrigerators and freezers with an opened (or prepared) date and expiration dates. The revised 06/1997 facility's policy for Storage of food and non-food items revealed all opened food items would be labeled with contents and dated. Further documented that cheese should be tightly wrapped. The facility failed to store food under sanitary conditions for the residents in the facility.…

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 The facility census totaled 43 residents with 12 residents included in the sample and two residents reviewed for hospitalization. Based on observation, interview, and record review the facility failed to send a copy of the facility- initiated hospitalization transfer/discharge notice to the Office of the State Long- Term Care Ombudsman for Residents (R)40 and R 34. Findings included: - R 40's signed physician orders dated 12/25/22, revealed the following diagnoses: alcohol dependence, in remission (consumption of alcohol in large quantities on a routine basis), atrial fibrillation (rapid irregular heartbeat), history of falling, unsteadiness on feet, and muscle weakness. The admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of four indicating severe cognitive impairment. The resident required extensive assistance of staff with transfers and ambulation. The resident had falls prior to admission with no fracture, and no falls since admission. The Significant…

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.

The facility census totaled 43 residents, with 12 sampled, including five residents for unnecessary medications. Based on interview and record review, the facility failed to ensure adequate monitoring for one of the five residents reviewed, regarding Zoloft (antidepressant- class of medications used to treat mood disorders and relieve symptoms of depression) and a lab for diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) for Resident (R) 21, by not decreasing the dose of this medication as ordered and not having the lab results available for review. These failures placed the resident at risk for adverse effects related to medication use. Findings Included: - The 02/07/23 Electronic Health Record (EHR) documented diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness) and diabetes mellitus. The 12/23/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of zero, indicating severely impaired cognition.…

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.

The facility reported a census of 32 residents. Based on interview and record review the facility failed to employ a Certified Dietary Manager (CDM). Findings Include: - On 07/13/21 at 11:50 AM Dietary Staff (DS) J confirmed she was not a CDM. She stated that her plan was to attend courses as soon as she could get registered, explaining that since Covid-19 it was difficult to register for classes. On 07/14/21 at 01:39 PM Administrative staff A stated DS J the had taken the courses but had not tested, also that the registered dietician had found out recently that DS J could still test, even though courses were taken in the mid 1990's. Stated she was aware they were to have a CDM and confirmed that they do not currently. The facility failed to provide a policy on required dietary staff when requested on 07/15/21. The facility failed to employ a CDM in the allotted time.

The facility reported a census of 32 residents, with one central kitchen. Based on observation, interview, and record review, the facility failed to store foods safely and sanitary by the staff's failure to date and reseal opened food items, failure to discard expired food items, and failure to use gloves appropriately in the kitchen. Findings included: - On 07/12/21 at 08:24 AM, during the initial tour of the main kitchen, the following was observed: In the walk-in refrigerator, noted one crate with 17 molded tomatoes, one bag of broccoli florets, one bag of carrots, and one bag of vegetable medley all opened and not dated, one eight ounce (oz) boost breeze (liquid nourishment) with a use-by date of 06/21/21, three eight oz boost breeze with a use-by date of 06/30/21, one eight oz ensure plus (liquid nourishment) with a use-by date of 09/01/20. In the refrigerator, noted one 24 oz container of cottage cheese expired on 07/07/21, one bag of sliced ham, and one bag of 22 hot dogs opened and not dated. During an interview on 07/12/21 at 09:03 AM, Dietary Staff (DS) J removed all items…

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.

The facility census totaled 32 residents, with three residents reviewed for beneficiary notices. Based on record review and interview, the facility failed to notify Resident (R)183 in advance of Medicare Part A (skilled) services ending on 05/06/21 per the Centers for Medicaid/Medicare Services (CMS) regulation. Findings included: - Review of R183's Notice of Medicare Non-coverage (NOMNAC) documented her Medicare Part A skilled services last covered day was 05/06/21, and the resident had signed the form. Review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage, (SNFABN) documented the form was not provided to R183 because the Social Services Director (SSD) was new and still learning the forms that were required. An interview with SSD D on 07/12/21 at 04:30 PM revealed she provided all residents with the NOMNAC at the end of skilled services but only provided the SNFABN to residents who remained in the facility after skilled services. She did not provide the SNFABN to residents who discharged from the facility after completing skilled services. SSD D stated…

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.

The facility reported a census of 32 residents with 12 residents included in the sample. Based on interview and record review the facility failed to prevent the misappropriation of resident's property, when the facility utilized Resident (R)133's government issued stimulus check to pay for facility charges on the resident's account without R133's consent. Findings included: - Review of the R133 personal funds revealed a deposit of $1200.00 from a government issued stimulus check. Further review revealed the facility used R133's stimulus check to make a payment to the facility, towards his account. Review of R133's record revealed no evidence of resident consent for the transaction. Interview with Business office staff C on 7/14/21 at 03:01 PM revealed R133 would not sign the check they had sent to him at the other facility where lived prior to admission to the current facility. The funds were placed back into R133's account and Business office staff C wrote a check from the account to the facility to apply the amount of the stimulus check to the account. Interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 32 residents, with 12 sampled, including five for unnecessary medications. Based on interview and record review, the facility failed to address the consultant pharmacist's recommendations for Resident (R)2. Findings included: - Review of R2's Physician's Orders in the Electronic Medical Record (EMR) dated 07/26/21 included a diagnosis of major depressive disorder (major mood disorder). A review of the Significant Change Minimum Data Set (MDS), dated [DATE], documented R2 received scheduled pain medication, as well as seven out of the seven-day observation period of antipsychotics (class of medications used to treat psychosis and other mental and emotional conditions) and antidepressants (class of medications used to treat mood disorders and relieve symptoms of depression). Review of the Psychotropic Drug Use Care Area Assessment (CAA), dated 08/04/20, documented that the resident had a potential for issues related to psychotropic medications and that pharmacy reviews were to 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 The facility reported a census of 32 residents, with 12 sampled and five reviewed for unnecessary medications. Based on interviews and record review, the facility failed to adequately follow the physicians' diabetic orders and document appropriately for Resident (R)2. Findings included: - Review of R2's Physician's Orders Electronic Medical Record dated 07/26/21 included a diagnosis of Diabetes Mellitus (DM; when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). A review of the Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R2 received insulin (mediation that regulates the amount of glucose in the blood) seven out of a seven-day observation period. Review of the Care Area Assessment (CAA) dated 08/04/20 documented no applicable CAAs triggered. A review of the Quarterly MDS dated 04/07/21, documented a BIMS score of 13, indicating intact cognition. R2 received…

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 The facility reported a census of 32 residents, with 12 sampled, including five for unnecessary medications. Based on interview and record review, the facility failed to adequately ensure gradual dose reductions (GDR's) were attempted for Resident (R) 2. Findings included: - Review of R2's Physician's Orders in the Electronic Medical Record (EMR) dated 07/26/21 included a diagnosis of major depressive disorder (major mood disorder). A review of the Significant Change Minimum Data Set (MDS), dated [DATE], documented R2 received scheduled pain medication, as well as seven out of the seven-day observation period of antipsychotics (class of medications used to treat psychosis and other mental and emotional conditions) and antidepressants (class of medications used to treat mood disorders and relieve symptoms of depression). Review of the Psychotropic Drug Use Care Area Assessment (CAA), dated 08/04/20, documented that the resident had a potential for issues related to psychotropic medications and that pharmacy…

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.