Inspection Reports for Trinity Elms

The visit was complaint-related due to a medication error reported on 4/24/25 involving the wrong medication, administration procedure not followed, and wrong resident. The error was substantiated as the medication aide mistakenly administered another resident's medications to Resident #1. The resident was monitored and sent to the hospital for precautionary evaluation with no adverse effects noted.

The facility failed to ensure residents were free from significant medication errors, specifically when Resident #1 was given another resident's medications. The error was reported, and the resident was sent to the hospital for evaluation as a precaution. No adverse drug effects were noted, and the resident was stable throughout the incident and hospital stay.

The facility was found to have discrepancies in advance directive documentation, failed to post required oxygen safety signage for residents receiving oxygen, left medications unsecured at bedside for one resident, and submitted inaccurate payroll data for nurse staffing which was later corrected.

The facility failed to provide adequate supervision for a resident with multiple falls resulting in injuries, failed to ensure referral and follow-up for residents related to nutritional supplements and medication refusals, lacked matching therapeutic diet menus for residents with special diets, failed to administer medications as ordered for some residents, and failed to observe a resident taking medications as required.

Complaint investigation revealed that Resident #1 was left unattended in the shower with water running, resulting in thermal burns. The facility failed to notify the medical provider promptly and did not supervise the resident adequately. The immediate jeopardy was removed after corrective actions including staff education and quality assurance audits.

Resident #1, a severely cognitively impaired and nonverbal resident, sustained deep partial thickness burns to bilateral anterior and medial thighs and mons pubis after being left unattended in the shower with water running. Facility staff failed to notify the medical provider timely and did not provide adequate supervision during the shower. The resident was hospitalized and treated with wound care and pain medication. Interviews, observations, and medical records confirmed the incident and deficient practices.

The facility failed to correct cited deficiencies related to exhaust ventilation systems not drawing in multiple required spaces, including bathrooms and environmental services areas.

The complaint investigation revealed that the facility failed to report an allegation of resident-to-resident abuse involving Resident #2 to Adult Protective Services within the required timeframe. The initial report was faxed late and APS was notified only after the 5-day investigation was completed. The Administrator had a prior agreement with the county DSS/APS to send reports after investigations.

The facility failed to report an allegation of resident abuse within the required timeframe for one resident and failed to maintain a medication error rate below 5%, with a medication error rate of 7.69% for one resident. Interviews and record reviews confirmed these deficiencies.

The complaint involved an allegation of resident-to-resident abuse (Resident #2) that was not reported to Adult Protective Services within the required timeframe. The facility reported to APS only after the 5-day investigation was completed, contrary to policy and regulatory requirements.

The facility failed to report an allegation of resident-to-resident abuse within the required timeframe. The Initial Allegation Report was faxed late, and notification to Adult Protective Services was delayed until after the 5-day investigation period, contrary to policy requirements.

Multiple deficiencies were cited including mechanical systems not kept clean, emergency equipment not maintained in safe operating condition, fire-resistance-rated enclosures not properly maintained, electrical system safety issues, and failure to provide working exhaust ventilation in required spaces.

The facility was found deficient in multiple areas including failure to complete competency validation for licensed health professional support tasks for some staff, failure to ensure physician notification for resident treatment refusals, failure to administer medications as ordered including missed medication refills and improper administration of blood pressure medication, failure to observe residents taking medications, and failure to act on pharmacist medication review recommendations.

The facility failed to maintain an indwelling urinary catheter bag and a nephrostomy bag off the floor for Resident #25, and failed to ensure opened foods in the kitchen were sealed, labeled, and dated according to professional standards.

The facility was found to have multiple deficiencies related to building code compliance including missing vision panels on smoke barrier doors, obstructions in corridors, improper handling of medical oxygen cylinders, lack of GFCI protection on electrical outlets near sinks, malfunctioning fire-rated doors, compromised fire-rated walls and ceilings, and the presence of a prohibited portable electric heater. Some deficiencies were corrected during the survey.

The followup survey revealed that all deficiencies have not been corrected. Deficiencies included unsecured oxygen cylinders, non-functioning emergency lights and exit signs on battery backup, compromised fire-rated walls, and hot water temperature exceeding allowed limits due to cross connection of chemical dispensing equipment.

The survey identified multiple deficiencies including missing annual fire sprinkler inspection report, loosely mounted hand grips in bathrooms, unsafe storage of oxygen cylinders, damaged bathroom door, failure to inspect kitchen fire suppression system monthly, incomplete fire drill rehearsals, non-functioning emergency lights and exit signs, compromised fire-rated walls and doors, lack of power to GFCI receptacles, and hot water temperature exceeding safe limits.