Trinity Manor

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe facility census totaled 41 residents with one resident sampled for accidents. Based on observation, interview, and record review, the facility failed to provide adequate supervision and ensure a safe and secure environment as free from accident hazards as possible when Housekeeping/Laundry Staff C failed to report a malfunctioning basement door. About six weeks later, on 07/01/24, cognitively impaired Resident (R)1 opened the same malfunctioning, key coded basement door and fell down seven steps to the landing, in her wheelchair. R1 sustained major injuries including a lump to the back of her head and three fractured ribs. This deficient practice placed R1 in immediate jeopardy and at risk for personal injury. (R1)

Inspectors wroteThe facility reported a census of 41 residents with three residents sampled for safety related to transportation outside the facility. Based on observation, interview, and record review, the facility failed to ensure staff provided a safe environment as free of accident hazards as possible, when Social Services Designee (SSD) C failed to ensure the lap belt was snug on Resident (R)1 prior to transport in the facility van while traveling on the highway. R1 fell out of the wheelchair onto the floor of the facility van, landing on his knees. SSD C failed to notify 911 or activate EMS for assistance. SSD C assisted R1 to lay on the floor of the van and then drove R1 back to the facility (approximately 20 miles), unsecured, and laying on the floor of the wheelchair van. [...]

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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: [...]

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.