Inspection Reports for Trinity Healthcare Center

The State Agency conducted a complaint investigation (CI) MS #29070 at the facility on 06/18/2025.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and no deficiencies were cited.

Complaint investigation MS #29070 was conducted and found no deficiencies; the facility was in compliance.

The State Agency conducted a complaint investigation (CI) MS #29070 at the facility on 06/18/2025.

The facility was found to be in compliance with Medicare and Medicaid Services requirements and no deficiencies were cited.

Complaint investigation MS #29070 was conducted and found no deficiencies; the facility was compliant.

The State Agency conducted an on-site revisit at the facility on 7/1/2024 related to a re-certification survey conducted 5/28/2024 through 5/30/2024.

The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back into compliance effective 6/19/2024.

The State Agency conducted an on-site revisit at the facility on 7/1/2024 related to a re-certification survey conducted from 5/28/2024 through 5/30/2024.

The facility was found to be following the regulatory requirements for The Aged and Infirm and is recommended to be placed back in compliance effective 6/19/2024.

The inspection was conducted due to a complaint investigation regarding the misappropriation of a resident's personal property by a staff member.

The facility failed to safeguard a resident's personal property when a Certified Nurse Assistant (CNA #1) was observed on camera taking a bottle of lotion from Resident #23's room and placing it in her pocket. The misappropriation was substantiated, and the CNA was suspended and terminated. Resident #23 was severely cognitively impaired and unaware of the missing item.

The complaint investigation substantiated abuse by means of misappropriation of Resident #23's property by CNA #1. The CNA was suspended and terminated following the investigation. Resident #23 was severely cognitively impaired and unaware of the missing lotion.

The inspection was conducted based on complaints regarding failure to provide timely notification of resident transfers, inadequate care planning and pain management, failure to assist with activities of daily living, unsafe storage of narcotics, and infection control concerns.

The facility was found deficient in multiple areas including failure to send written transfer/discharge notices to resident representatives, inadequate comprehensive care plans for residents with pain and ADL needs, failure to provide appropriate pain management, failure to assist a resident with shaving, unsafe storage of controlled substances, and improper storage of respiratory suctioning equipment leading to infection control risks.

The visit was complaint-related, triggered by allegations of failure to notify resident representatives of transfers, inadequate care planning and pain management, failure to assist with ADLs, unsafe narcotic storage, and infection control issues. Substantiation status is not explicitly stated.

The State Agency conducted an annual re-certification survey from 5/28/24 through 5/30/24 along with a complaint investigation (CI) MS #25191 to assess compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The facility was found not in compliance with standards at M610, M705, and M1570 related to activities of daily living, medication storage, and infection control. The complaint investigation was substantiated for misappropriation of a resident's property. Corrective actions were initiated including staff termination and policy updates.

Complaint investigation MS #25191 was substantiated for misappropriation of a resident's property involving a Certified Nurse Assistant (CNA #1) who was observed on camera taking a bottle of lotion from Resident #23's room. The CNA was suspended and subsequently terminated following the investigation.

The State Agency conducted an annual re-certification survey along with a complaint investigation at the facility from 5/28/24 through 5/30/24 to determine compliance with Medicare and Medicaid requirements.

The facility was found not in compliance with several Medicare and Medicaid participation requirements including failure to prevent misappropriation of resident property, failure to send required transfer/discharge notices, incomplete comprehensive care plans, inadequate pain management, improper storage of narcotics, and infection control issues related to suction equipment storage.

The complaint investigation (CI) MS #25191 was conducted concurrently with the annual survey. The facility was found in compliance with the complaint investigation but cited for past non-compliance related to failure to prevent misappropriation of a resident's property.

The inspection was conducted as an annual survey to assess compliance with Federal, State, and local emergency preparedness requirements and the Life Safety Code (LSC).

The facility met all applicable emergency preparedness requirements and the Life Safety Code provisions. The State Agency recommended the facility be placed back in compliance effective 06/19/24 after reviewing corrective measures.

The inspection was conducted to assess compliance with the Life Safety Code (LSC) requirements, specifically focusing on hazardous areas and emergency preparedness.

The facility met all applicable emergency preparedness requirements but failed to properly protect hazardous areas as required by NFPA 19.3.2.1.2. Specifically, three of six smoke compartments and 23 of 59 residents were affected due to doors lacking required self-closing or automatic closing devices.

The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.

The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies noted.

The State Agency conducted a desk review related to the annual survey conducted on 05/29/24 to verify correction of deficient practices.

The facility provided information confirming corrective measures were implemented to sustain compliance with the 2012 Edition of the Life Safety Code. The State Agency recommends the facility be placed back in compliance effective 06/19/24.

The State Agency conducted a desk review of information related to the annual survey completed on 2023-03-09 to verify compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The facility was confirmed to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm based on the desk review.

The State Agency conducted a desk review of information related to the annual survey completed on 2023-03-09 to verify corrective measures taken by the facility.

The facility provided information confirming that corrective measures were implemented to address deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2023-04-19.

The inspection was conducted to evaluate the facility's compliance with Medicare notification requirements, specifically regarding the provision of the Notice of Medicare Non-Coverage to residents discharged from Medicare Part A services with time remaining on their benefits.

The facility failed to provide the Notice of Medicare Non-Coverage to two of three residents discharged from Medicare Part A services with time remaining. Interviews revealed staff were unaware of the requirement to provide this notice, and record reviews confirmed the notice was not given to the affected residents.

The State Agency conducted an annual recertification survey from March 6, 2023 through March 9, 2023 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements at the time of the survey.

The State Agency conducted an annual re-certification survey at the facility from 03/06/2023 through 03/09/2023 to assess compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with Medicare and Medicaid requirements, specifically failing to provide the Notice of Medicare Non-Coverage to two residents discharged from Medicare Part A services with time remaining on their coverage.

The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA), focusing on smoke barrier construction and essential electrical system maintenance.

The facility failed to provide the required half-hour fire resistance rating in the smoke barrier wall, affecting two of three smoke compartments, and failed to properly document annual testing of the emergency generator, with the last documented test performed in January 2022.

The inspection was conducted to assess compliance with the Life Safety Code, specifically reviewing documentation of annual generator testing and smoke barrier integrity.

The facility failed to provide documentation of the 2023 annual generator testing, with the last test documented in January 2022. Additionally, the smoke barrier at 200 hall was sealed during the inspection, and maintenance procedures were updated to prevent future unsealed penetrations.

The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA), focusing on smoke barrier construction and essential electrical system maintenance.

The facility failed to provide the required half-hour fire resistance rating in the smoke barrier wall, affecting two of three smoke compartments, and also failed to properly document the annual testing of the emergency generator, with the last documented test performed in January 2022.

The facility was surveyed due to failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network as required by regulation.

The facility failed to report complete information about COVID-19 to the CDC's NHSN during a seven-day period between 08/29/2022 and 09/04/2022, which has the potential to cause more than minimal harm to all residents.

The State Agency conducted a complaint survey at the facility on 4/13/2022 to investigate a complaint identified as MS #00018342.

The survey determined that the facility was in compliance with the requirements for The Aged and Infirmed. The complaint for abuse, neglect, or quality of care was not substantiated and no deficiencies were cited.

Complaint MS #00018342 was investigated and found to be unsubstantiated for abuse, neglect, or quality of care.

The State Agency conducted a complaint survey at the facility on 4/13/2022 to investigate a complaint identified as MS #00018342.

The survey determined that the facility was in compliance with Medicare and Medicaid requirements. The complaint for abuse, neglect, or quality of care was not substantiated and no deficiencies were cited.

Complaint MS #00018342 was investigated and found not substantiated for abuse, neglect, or quality of care.

The State Agency conducted a COVID Infection Control survey at the facility on 08/18/20 to assess compliance with Medicare and Medicaid regulations.

The facility was found to be in compliance with Medicare and Medicaid regulations of participation during the COVID Infection Control survey.

The State Agency conducted a COVID Infection Control survey at the facility on 08/18/2020 to assess compliance with Medicare and Medicaid regulations.

The facility was found to be in compliance with Medicare and Medicaid regulations of participation during the COVID Infection Control survey.

The State Agency conducted a COVID Infection Control survey at the facility on 08/18/2020 to assess compliance with Medicare and Medicaid regulations.

The facility was found to be in compliance with Medicare and Medicaid regulations of participation during the COVID Infection Control survey.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.

A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparation.

A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and implementation of CMS and CDC recommended practices for COVID-19 preparation.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the recommended practices to prepare for COVID-19.

A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.

The inspection was conducted to assess compliance with regulatory requirements related to accurate resident assessments and safe dietary practices in the facility.

The facility failed to submit an accurate Minimum Data Set (MDS) assessment for one resident regarding medication administration, and failed to maintain a safe and clean dietary environment, including improper food labeling, storage, and unclean ovens.

The State Agency conducted an annual recertification survey along with a complaint investigation from 02/18/2020 to 02/20/2020. The complaint was not substantiated, but the facility was found not in compliance with Medicare and Medicaid participation requirements.

The facility failed to submit an accurate Minimum Data Set (MDS) assessment for one resident regarding medication administration and failed to maintain a safe and sanitary dietary environment, including unlabeled and undated foods and unclean ovens. Additionally, the facility failed to properly inspect fire doors as required by the Life Safety Code.

The complaint investigation (CI MS #16691) for allegation of abuse was not substantiated and no deficiencies were cited related to the complaint.

The State Agency conducted a recertification and complaint survey from 2/18/2020 to 2/20/2020. The complaint was not substantiated, but the survey found the facility was not in compliance with Minimum Standards for The Institutions For The Aged And Infirm.

The facility failed to provide a safe and clean dietary environment for food storage and service, including unlabeled and undated foods in refrigerators and unclean ovens with carbon build-up and charred food residue.

The complaint investigation was conducted but not substantiated; no state statutes were cited related to the complaint.

The State Agency conducted an annual recertification survey along with a complaint investigation from 02/18/2020 to 02/20/2020.

The complaint of abuse was not substantiated and no deficiencies were cited related to the complaint. However, the facility was found not in compliance with Medicare and Medicaid participation requirements and was cited for deficiencies F641 and F812.

The complaint investigation (Cl MS #16691) for allegation of abuse was not substantiated and no deficiencies were related to the complaint.

The State Agency conducted a licensure survey for complaint CI MS I# 0001646 on 01/02/2020 related to an entity reported incident for abuse and neglect.

The facility failed to ensure Resident #1's right to be free from abuse and/or neglect. The investigation revealed that a call light was intentionally disabled by a staff member, resulting in neglect. The responsible Licensed Practical Nurse (LPN #3) was terminated following substantiated findings.

The complaint investigation was substantiated. The facility's investigation found that LPN #3 intentionally disabled Resident #1's call light by unplugging it and inserting a drinking straw into the call box. LPN #3 was terminated and the incident was reported to the Mississippi Board of Nursing.

The State Agency conducted a complaint survey related to an entity reported incident for abuse and neglect at the facility on 1/2/2020.

The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to ensure Resident #1 was free from abuse and neglect. Specifically, the call light system for Resident #1 was intentionally disabled, constituting neglect by a licensed practical nurse, who was subsequently terminated.

The complaint investigation was substantiated based on record review, staff interviews, and facility policy review. The investigation found that LPN #3 willfully neglected Resident #1 by disabling the call light system. LPN #3 was terminated and the incident was reported to the Mississippi Board of Nursing.

The State Agency conducted an annual recertification survey at the facility from 3/19/19 to 3/19/19 to determine compliance with the Minimum Standards for the Aged or Infirmed.

The facility was found to be in compliance with no health deficiencies cited during the annual recertification survey on 3/19/19. However, a life safety code deficiency was identified on 3/20/19 related to the fire sprinkler system's failure to activate the fire alarm system within the required time.

The State Agency conducted an annual recertification survey at the facility to determine compliance with Medicare and Medicaid requirements.

The facility was found to be in compliance with Medicare and Medicaid requirements during the annual recertification survey. However, a deficiency was identified related to the sprinkler system supervisory signals not activating the fire alarm system within the required time.