Inspection Reports for
Trinity Healthcare Center

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

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

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 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 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 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.