Trinity Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and facility policy review, the facility failed to accurately complete and submit a Minimum Data Set (MDS) assessment for a resident not receiving hospice services for one (1) of 17 assessments reviewed. Resident #38 Findings include: Record review of facility policy titled, Conducting an Accurate Resident assessment dated 10/25, revealed, Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Resident #38 During the record review of Resident #38's Significant Change Minimum Data Set (MDS) Section O - Special Treatments, Procedures, and Programs dated 3/25/26, the data revealed the resident received hospice care while a resident at the facility. Record review of Resident #38's Clinical Physician Orders since his admission to facility on 12/23/25, revealed that hospice services had not been ordered. An interview…

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 facility policy review, the facility failed to ensure clean linens were transported in a manner to prevent contamination for one (1) of three (3) days of survey. Findings Include: Review of facility policy, Infection Prevention and Control Program with an implementation date of 10/2022, the policy stated, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. On 4/28/2026 at 11:34 AM, an unidentified staff member was observed transporting clean linens in a cart without a cover in the resident hallway. During an interview with the Administrator, she stated and confirmed, Staff members were educated on the safe transportation of resident's linens, and they are to be covered to prevent contamination.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review and facility policy review, the facility failed to send a written notice to the resident representative regarding a resident being transferred to the hospital for one (1) of three (3) residents reviewed for hospitalizations. Resident #8 Findings Include: Review of the facility policy titled, Transfer and Discharge dated 10/2022, revealed under, Policy Explanation and Compliance Guidelines .#4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand . Record review of Resident #8's hospital Discharge summary dated [DATE] revealed the resident was hospitalized for a possible head injury due to a fall. An interview on 5/29/24 at 11:05 AM, with the Licensed Practical Nurse (LPN)/Medical Records revealed she does not mail a transfer/discharge notice to the resident representative when the resident is discharged . She stated that there is a form in the facilities electronic…

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, resident and staff interview, record review, and facility policy review, the facility failed to provide assistance with activities of daily living (ADLs) for a resident dependent on staff for shaving for one (1) of sixteen sampled residents. Resident #17 Findings Include: Record review of the facility policy titled Grooming a Resident's Facial Hair undated, revealed under, Policy: It is the practice of this facility to assist residents with grooming facial hair to meet their preference. An observation of Resident #17, on 5/28/2024 at 11:06 AM, revealed he was sitting in a wheelchair in the day room. Gray facial hair observed on the sides of his face and above his lip, measuring approximately one-fourth (1/4) inch in length. An interview with Certified Nurse Aide (CNA) #2 on 5/29/2024 at 10:50 AM, revealed Resident #17 gets a shower on Tuesday, Thursday, and Saturday during the 3-11 shift. She confirmed the resident was unshaven, and reveled the resident should have been shaved yesterday, which would have been his scheduled shower day. An interview with Resident…

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 facility policy review, the facility failed to safely store narcotics in the medication room refrigerator for one (1) of two (2) medication rooms in the facility. (100 hall medication room) Findings include: Review of the facility policy titled, Controlled Substance Administration and Accountability, with an implementation dated of 10/2022, revealed it is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. An observation of the 100-hall medication room on 05/29/24 at 4:20 PM, with Licensed Practical Nurse (LPN) #1 revealed one vial of Ativan two (2) milligrams/one (1) milliliter in a clear plastic box in the refrigerator. The Ativan was not in a compartment secured to the refrigerator. This was confirmed by LPN #1. An observation and interview, on 05/30/24 at 9:10 AM, with the Director of Nursing (DON) confirmed the injectable…

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, record review, and facility policy review, the facility failed to store a respiratory suctioning device in a manner that prevented the possibility of the spread of infection for one (1) of two (2) residents with suction devices. Resident #23 Findings Include: Review of the facility policy titled Infection Prevention and Control Program undated, revealed under, Policy: This facility has established and maintains an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. An observation of Resident #23 on 5/28/2024 at 10:26 AM and 2:29 PM, revealed a suction machine with the attached tubing was placed on the floor beside the resident's bed, with an unbagged yankauer suction tool lying on the floor. Record review of the Order Summary Report for Resident #23 revealed an order dated 1/27/2024, Bedside suction with yankauer as needed for increased secretions. An…

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 staff interview, record review, and facility policy review, the facility failed to ensure that a resident's personal property was safeguarded, and that staff did not misappropriate property for one (1) of 56 residents residing in the facility. Resident #23. Based on actions taken by the facility on 5/23/24, this was determined to be Past Non-Compliance. Findings include: Review of the facility policy titled Abuse, Neglect, and Exploitation with a revision date of 3/15/204 revealed under, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Record review of the internal investigation conducted by the Administrator (ADM) dated 5/22/2024 for Resident #23 revealed, On May 21, 2024, at 3:30 PM, Director of Nursing (DON) reported to me that she suspected Certified Nurse Assistant (CNA) #1, had taken a bottle of lotion from an elder (Resident). The DON…

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 staff interview, record review, and facility policy review, the facility failed to provide the Notice of Medicare Non-Coverage to two (2) of three (3) residents discharged from Medicare Part A services with service times remaining. Resident #27 and Resident #49 Findings include: Review of facility policy titled, Advanced Beneficiary Notices, with revision date of October 2022, revealed, It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. Review of facility policy also revealed, 5. The current CMS-approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). The contents of the form shall comply with related instructions and regulations regarding the use of the form. a. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice, . c. A Notice of Medicare Non-Coverage . shall be issued to the resident/representative when Medicare covered…

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.