Trinitas Hospital

Inspectors wroteBased on observation and interviews, it was determined that the facility failed to maintain the most recent State of New Jersey inspection results in a place readily accessible to the residents, families, and the public. The deficient practice was identified on 3 of 3 units. This deficient practice was evidenced by the following: During the Resident Council Meeting on 01/15/2025 at 10:00 AM, five of five alert and oriented residents said they were not aware of the location of the State Survey results and that the facility had not spoken to them about the results. During a tour of each unit, the surveyor had to ask at the nurse's station where the State survey results binder was kept. The surveyor was told by the unit secretary or nurse that was at the desk at each unit that it was located behind the nurse's station. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain a clean, safe, and sanitary environment for 2 of 3 units (South and North Units). This deficient practice was evidenced by the following: On 01/12/2025 at 10:28 AM, Surveyor #1 observed the baseboard trim in room [ROOM NUMBER] detached from the wall on the North Unit. On 01/13/2025 at 10:35 AM, Surveyor #1 observed water stains on the ceiling tiles in the shower room on the North Nursing Unit. On 01/13/2025 at 10:43 AM, Surveyor #1 observed the shower room on the North Nursing Unit, which including a portable commode, three commode buckets, a commode lid, and a non-stick food placement mat placed on a chair in the corner. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents it was determined that the facility failed to use appropriate infection control practices, such as hand hygiene and Personal Protective Equipment (PPE) when providing care and other high-contact care activities to 3 of 3 residents (Resident #23, #52, #84) reviewed under the Infection Control Task. The deficient practices were evidenced by the following: 1. On 1/14/2025 at 10:24 AM, surveyor #1 observed Licensed Practical Nurse (LPN#1) perform tracheostomy (a small surgical opening that is made through the front of the neck into the windpipe) care, which was identified as requiring aseptic techniques (a set of practices that prevent the spread of infection) on Resident #52 and observed the following: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide privacy for a resident during hygienic care. Specifically, the bedroom and bathroom doors were not closed, exposing the resident's upper body. This deficiency was noted for 1 out of 20 residents (Resident # 38) reviewed. This deficient practice was evidenced by the following: On 01/13/2025 at 10:19 AM, the surveyor observed Resident # 38 in the bathroom sitting on the toilet, with the wheelchair positioned in front of the resident while getting dressed. The door was open, exposing the resident's upper body. During an interview with the surveyor on 01/13/2025 at 10:39 AM, the Licensed Practical Nurse #1 (LPN #1) said that she was uncertain whether the bedroom and bathroom doors should remain open during the time the resident was getting dressed. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to keep the call device system within reach for a resident who was dependent on staff. This deficiency was identified for 1 out of 1 resident (Resident # 32) reviewed for Accommodation of Needs. This deficient practice was evidenced by the following: On 01/13/2025 at 10:01 AM, the surveyor reviewed the electronic medical records (EMR) for Resident #32. The EMR revealed that he/she had a diagnoses of but not limited to Dementia and Alzheimer's Disease (cognitive disease). A review of the significant change in status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/20/2024 indicated that Resident #32 had severe cognitive impairment and was dependent in both self-care and mobility. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set death in facility tracking record in accordance with federal guidelines. This deficient practice was identified for 1 of 2 residents reviewed for resident assessment (Resident #58). This deficient practice was evidenced by: On [DATE] at 12:07 PM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. On [DATE] at 12:07 PM, the surveyor reviewed Resident #58's electronic medical record. The record revealed that the resident expired on [DATE]. The electronic health record reflected that there was no death in facility tracking record completed for the resident's death date of [DATE]. On [DATE] at 12:13 PM, the surveyor interviewed the MDS Coordinator. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive care plan to address an elopement alarm for 1 of 23 residents (Resident #59) reviewed. The deficient practice was evidenced by the following: On 01/12/25 at 10:00 AM, the surveyor observed Resident #59 in the room with an elopement alarm on the left ankle. The surveyor reviewed Resident #59's medical record which reflected that the resident had diagnoses which included muscle weakness and anxiety. A review of the physician orders for Resident # 59 reflected an order dated 09/10/21 for the resident to have a wanderguard. The minimum data set, an assessment tool, dated 11/8/24 Q MDS reflected that Resident #59 used an elopement alarm used daily. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to transmit a Minimum Data Set (MDS) - Annual and Quarterly Reporting Assessment in accordance with federal guidelines. This deficient practice was identified for 13 of 13 residents reviewed for resident assessment (Resident #43, #44, #23, #5, #51, #53, #49, #20, #1, #26, #16, #65, #64). This deficient practice was evidenced by: On 8/25/23 at 11:30 AM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. A MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accurately code resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for one 1 of 18 residents, (Resident #3) reviewed for accurate coding of MDS. This deficient practice was evidenced by the following: On 8/24/23 at 9:54 AM, Resident #3 was observed sitting on wheelchair in hallway, able to wheel self around unit. The Resident responded to the surveyor appropriately when spoken to stating that they were ok and had no issues with care. The Resident refused to continue the interview. The surveyor reviewed the resident's hybrid medical chart which included review of paper as well as computerized medical chart. [...]

Inspectors wroteBased on observation, interview and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On 6/23/21 at 09:49 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and the Executive Chef (EC) and observed the following: 1. In the production area, there was one bag of kaiser rolls with no identification on the bag, no opened or use by dates. 2. In the prep fridge #16, there were five small individually wrapped styrofoam plates in clear plastic that contained tomato and lettuce dated use by 6/22/21. [...]