Trinity Regional Rehab Center

Inspectors wroteBased on observations, interviews and record review, the facility failed to protect the residents' right to be free from neglect by failing to respond to an exit door alarm and provide supervision to prevent an elopement for one (Resident #1) out of three residents sampled. On 1/11/26, approximately 2:15 p.m., Staff F, Certified Nursing Assistant (CNA), discovered Resident #1 was not in his room. At 2:15 p.m., a Dr. Walker (code announced overhead to indicate a potential missing resident) was called in the facility. Resident #1 exited the facility without staff knowledge from the second-floor hallway next to the Maintenance Directors office into the stairwell leading to the first floor. Resident #1 proceeded down the stairs to the first floor through an unlocked door with no alarm. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide adequate supervision to one resident (Resident #1) who was cognitively impaired and identified as an elopement risk, from exiting the facility out of three residents sampled. On 1/11/26, approximately 2:15 p.m., Staff F, Certified Nursing Assistant (CNA), discovered Resident #1 was not in his room. At 2:15 p.m., a Dr. Walker (code announced overhead to indicate a potential missing resident) was called in the facility. Resident #1 exited the facility without staff knowledge from the second-floor hallway next to the Maintenance Directors office into the stairwell leading to the first floor. Resident #1 proceeded down the stairs to the first floor through an unlocked door with no alarm. [...]

Inspectors wroteBased on interview and record review, the facility failed to honor a resident's right to a safe, orderly, and planned discharge for one (#1) of one resident discharged while an appeal was pending. Findings Included: During a telephone interview on 05/01/2025 at 2:32 p.m., Resident #1 stated she was discharged from the facility on 04/29/2025 while awaiting a hearing discharge. She stated she called to file the appeal on what she thought was the 10th day, but the facility told her she filed the appeal on the 11th day and would still be discharged home. The resident stated she was not ready to come home and could not afford to pay her portion of the bill. She stated she could not go home without a sit- to stand lift which she required for transfers. Resident #1 stated she was still waiting for an upright walker because she cannot really stand. [...]

Inspectors wroteBased on observation, record review and interviews the facility failed to ensure four kitchen staff members (Certified Dietary Manager, A, B, and C) wore hairnets, beard guards and gloves in accordance with professional standards for food service safety, in one of one kitchen observed.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure prompt efforts were made to resolve grievances for Resident Council for four months (June, July, October and November 2024) of six months reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four residents (#413, #42, #263, and #264) of four residents reviewed for wound care concerns received wound care treatment in accordance with professional standards of practice.

Inspectors wrote2. An observation of Resident #59's room on 11/18/24 at 11:11 a.m., revealed 11 packets of peri-care ointment, 5 grams each, laid on top of a nightstand. An interview was conducted following the observation with Resident #59. Resident #59 stated he was unaware the ointments were left on the nightstand. Review of the admission Record showed Resident #59 was re-admitted to the facility on [DATE]. There were no medication self-administration assessments found in Resident #59's medical record. The Order Summary Report showed no orders for Resident #59 to self-administer his own medications. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement safety precautions for smoking supplies for one resident (#52) of one sampled resident for smoking.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a central line dressing was changed as ordered for one resident (#33) out of four residents sampled.

Inspectors wroteBased on observation, record review, and interview, the facility failed to accommodate food preferences for two residents (#90 and #263) of six sampled residents.

Inspectors wroteBased on observation, interview, and policy review, the facility did not ensure appropriate infection control practices on two of two units related to respiratory equipment being left uncovered for one (#103) of one resident sampled for respiratory concerns, an ice scoop left uncovered in a hall, handling of clean linens, cleaning of glucometers, and contact precautions for one (#263) of two residents sampled for transmission-based precautions.

Inspectors wroteBased on staff interviews and record review the facility failed to provide three (#33, #43, and #114) of three residents sampled for hospitalizations with written notification and completed notification of transfers and failed to notify the State Long-Term Care Ombudsman Council (LTCOC) office of transfers.

Inspectors wroteBased on interviews, record reviews and observations, the facility failed to ensure four Residents (#26, #49, #64, #84) of four residents sampled received restorative nursing services in order to maintain their ability to perform activities of daily living. Findings Included: 1) During an interview on [DATE] at 2:22 p.m. Resident #26 stated he had not had a shower in 10 days and feels like he gets restorative nursing when he is in the shower but has not received the restorative nursing program he was told he would get. The resident stated he is not progressing forward and wants to go home but is not sure if that will be possible. Review of the care plan problem area dated [DATE] revealed the resident's ADL/restorative nursing program required active range of motion to bilateral upper extremity 6 days per week. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and four errors were identified for three (#75, #81, and #28) of five residents observed. These errors constituted a 16% medication error rate.

Inspectors wroteBased on staff interviews and record review the facility failed to provide a Bed Hold Policy prior to transfers for two (#33 and #43) of three residents sampled for hospitalizations.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two residents (#86 and #26) were provided the correct size brief and incontinence care in order to provide comfort and maintain skin integrity of 3 residents sampled. Findings Included: 1) An interview with Resident #26 on 4/19/21 at 11:30 a.m. revealed the resident preferred the green briefs but stated they give him the yellow briefs which are too tight and hurt his (testicles). An interview with Resident #26 on 4/20/21 at 9:53 a.m. revealed the resident was showered yesterday and has been wearing the yellow briefs. Resident #26 stated he needs the green ones as the yellow ones are too tight for him and hurt. He stated when he urinates in the brief it gets tighter and starts hurting more but the green ones give him room and did not hurt. During an interview with Resident #26 on 4/21/21 at 9:35 a.m. [...]

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure respiratory equipment was stored in a sanitary manner and had a physician order for the use of a Continuous Positive Airway Pressure (CPAP) machine for one (#265) out of two residents sampled for respiratory care.

Inspectors wroteBased on observations, interviews, and policy review the facility failed to store medications with an appropriate pharmacy label, failed to dispose of expired medications, failed to ensure two of four treatment carts and one of six medication carts were inaccessible to residents and visitors.