Inspection Reports for
Trinitas Hospital

Complaint #NJ180911 triggered the survey conducted from 01/12/2025 to 01/16/2025. The complaint involved issues such as privacy violations, call system accessibility, staffing shortages, and environmental concerns. The complaint was substantiated with multiple deficiencies cited.

Deficiencies were cited related to resident rights including failure to provide privacy, reasonable accommodations, staffing shortages, safe environment, infection control, and care planning. Immediate actions and systemic changes were implemented to address these issues.

The facility was found deficient in multiple areas including failure to provide privacy during hygienic care, failure to keep call devices within reach for dependent residents, failure to maintain accessible survey results for residents, failure to maintain a clean and homelike environment, failure to complete and transmit required resident assessment data, failure to develop comprehensive care plans for elopement alarms, and failure to implement proper infection prevention and control practices including hand hygiene and use of personal protective equipment.

The visit was complaint-related based on complaints NJ00166073, NJ00166001, and NJ00164909. The deficiencies cited were substantiated by observations, interviews, and record reviews during the survey.

Deficiencies were cited related to failure to timely transmit Minimum Data Set (MDS) assessments for 13 residents, inaccurate coding of MDS assessments for one resident, failure to maintain required minimum direct care staff-to-resident ratios, and lack of emergency lighting at the emergency generator transfer switch.

The visit was complaint-related, focusing on late transmission of MDS assessments and inaccurate coding of resident falls. The facility acknowledged the late transmissions and missed coding during interviews with the MDS Coordinator, Licensed Nursing Home Administrator, and Director of Nursing.

The facility failed to transmit MDS Annual and Quarterly Reporting Assessments within the federally mandated 14-day timeframe for 13 residents. Additionally, the facility inaccurately coded the MDS for one resident by not documenting multiple falls that occurred, contradicting progress notes.

The facility was found not in compliance with 42 CFR 483.80 infection control regulations, specifically failing to notify resident representatives by 5 PM the next calendar day following a single confirmed COVID-19 infection. This deficiency was identified for 3 of 3 sampled residents. A follow-up revisit on 1/12/2023 confirmed that corrective actions were completed.

Complaint NJ00157843 was substantiated. The facility was found not in substantial compliance with requirements based on the complaint visit. An Immediate Jeopardy situation was identified due to unlocked medication carts accessed by a resident, resulting in an overdose and hospital admission.

The facility failed to ensure medications were stored securely and inaccessible to high-risk residents, resulting in a resident accessing unlocked medication and an overdose incident. The facility was not in substantial compliance with long term care requirements and had an Immediate Jeopardy situation due to staff leaving medication carts unlocked.

Complaint numbers NJ00155311 and NJ00155477 triggered the visit. The facility was found not in substantial compliance based on these complaints.

The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on complaint findings. Deficiencies included failure to honor resident meal preferences for 2 of 8 residents, failure to maintain required minimum direct care staff-to-resident ratios for multiple days, and failure to ensure residents received at least one bath or shower per week for 2 of 3 residents reviewed.

The facility failed to properly handle and store potentially hazardous foods to prevent food borne illnesses and failed to maintain equipment and kitchen areas to prevent microbial growth and cross contamination. Multiple instances of unlabeled, expired, unsealed, or improperly stored food items were observed, and the meat slicer was found with debris and inadequate cleaning records.

The facility failed to properly handle and store potentially hazardous foods, maintain equipment and kitchen areas to prevent microbial growth and cross contamination, and adhere to labeling and expiration date protocols. Numerous instances of unlabeled, expired, or improperly stored food items were observed, and cleaning procedures for equipment such as the meat slicer were inadequate.

The facility was found not in compliance with infection control regulations, specifically failing to practice appropriate hand hygiene for 1 of 5 staff and improperly placing housekeeping carts inside resident rooms on 4 units, contrary to CDC guidelines to mitigate COVID-19 spread.

The facility failed to hire a qualified Infection Control Preventionist as required by the Executive Directive. The hospital's Infection Preventionist worked full time at the hospital and only part time (approximately 10 hours per week) for the long-term care facility, with no contract evidence provided. This was deemed a deficiency in infection control compliance.