Inspection Reports for
Trinity Center at Luther Park

Complaint #2696701-C resulted in a deficiency related to the right to be free from chemical restraints.

The facility was found deficient in multiple areas including failure to document non-pharmacological interventions prior to administering psychotropic medications, failure to notify resident representatives in writing of hospital transfers and bed hold policies, inaccurate Minimum Data Set (MDS) coding, failure to provide consistent COVID-19 assessments and monitoring, failure to complete neurological assessments after falls, failure to use gait belts during resident transfers, failure to label and properly handle food and food storage, and failure to follow infection prevention and control protocols including PPE use and COVID-19 transmission precautions.

The facility was found to have multiple deficiencies including failure to notify the Long Term Care Ombudsman of resident transfers, incomplete discharge summaries and plans, improper food handling and infection control practices. The facility provided a plan of correction and education to staff to address these issues.

Complaint #122230 was substantiated. Facility Reported Incident #119816-I was substantiated. The investigation was based on complaints and incidents from August 12-15, 2024. The facility failed to complete required incident reports and notifications, and did not conduct thorough investigations including staff interviews for alleged abuse.

The facility failed to complete an incident report and notify the physician and resident's emergency contact for a new bruise found on a resident. The investigation revealed inadequate staff interviews and incomplete documentation related to alleged abuse. The facility policy on notification of changes and abuse investigation protocols were not fully followed.

Complaints #109327-C and #109270-C were substantiated as stated in the initial comments on page 1.

The facility was found to have failed to report an unusual occurrence to the state agency in a timely manner, failed to provide basic life support including CPR to a resident requiring emergency care, and failed to serve correct diets to residents as ordered by physicians. The facility also failed to prevent serious bodily injury to a resident and had deficiencies related to abuse reporting and nutritional adequacy.

Complaints #99662-C, #99664-C, #104834-C were substantiated. Self Report #99883-1 was substantiated.

The facility was found to have multiple deficiencies including failure to honor resident medication and treatment preferences, lack of process for unidentified personal property, failure to document rationale for emergency discharge, failure to notify residents or responsible parties of bed hold policy, failure to develop and implement interventions for edema management, failure to maintain professional standards in medication administration, failure to meet nutritional needs with correct serving sizes, failure to maintain infection control practices, failure to respond to call lights timely, failure to store drugs according to professional standards, and failure to maintain clean and labeled foods in personal refrigerators.

Facility Reported Incident #97074 was substantiated.

The facility failed to intervene after receiving a critical potassium laboratory value for a resident, resulting in the resident's death due to acute kidney failure caused by hyperkalemia. Staff failed to notify the resident's physician and document the critical lab results properly.

Complaint #96938-C and #96496-C were substantiated. Facility Reported Incident #93593-I was not substantiated. Facility Reported Incidents #96380-I and #96670-I were substantiated.

The facility was found to have failed to report an allegation of abuse within 24 hours, failed to administer medications as ordered for one resident, failed to provide adequate supervision to prevent accidents for six residents, and failed to ensure residents were free from significant medication errors and food safety violations.

The visit was complaint-related, investigating incidents #87555 and #87943. Incident #87943 was substantiated based on clinical record review, staff and resident interviews, and observations.

The facility failed to provide adequate supervision for Resident #1, resulting in a fall and fracture due to being left unattended on the toilet despite alarms. The investigation revealed staff did not follow protocols to prevent falls and left the resident unattended, leading to injury.