Inspection Reports for Trinity Hill Care Center LLC

An unannounced visit was made to Trinity Hill Care Center by the Department of Public Health for the purpose of conducting an investigation related to complaint #43677.

The facility was found to have failed to ensure a resident was free from physical abuse and failed to meet staffing levels according to Connecticut Public Health Code. Specific incidents of resident-to-resident physical abuse were documented, and staffing hours were below required levels on multiple days.

Complaint #43677 triggered the investigation. The complaint involved allegations of physical abuse between residents. The investigation substantiated the abuse with documented incidents and witness statements.

The visit was a desk audit and monitoring inspection to review the implementation of the Plan of Correction for previously identified violations.

All previously identified violations listed in the violation letter dated 2024-11-15 were corrected as of 2024-11-27. The Director of Nursing was notified by telephone on 2024-12-27 that all violations were corrected.

The inspection was conducted as a complaint investigation related to complaint investigations #41691, #41701, and #41471.

No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.

Complaint investigations #41691, #41701, and #41471 were reviewed; no violations were substantiated.

The inspection was conducted as a licensing inspection for renewal purposes and included review of complaint investigations #39533 and #40051.

No violations of the General Statutes of Connecticut or regulations were identified at the time of this inspection.

A desk audit was conducted on 4/11/24 for the purpose of renewing the implementation of the plan of correction for the violation letter dated 3/11/24.

The desk audit found that violation #1 was corrected as of 3/5/24, and on 4/11/24 the administrator was notified via telephone that all violations were corrected.

An unannounced visit was made to Trinity Hill Care Center for the purpose of conducting a complaint investigation related to alleged violations of Connecticut State regulations.

Violations of Connecticut State regulations were identified during the investigation, specifically related to medication administration errors involving insulin and blood sugar monitoring for a resident with diabetes. The facility failed to ensure proper transcription and administration of insulin orders and documentation of finger stick blood sugar monitoring.

Complaint investigation #35239 was conducted. Violations were substantiated as violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified.

Unannounced visits were made to Trinity Hill Care Center for the purpose of conducting a complaint investigation related to allegations of abuse.

The investigation found allegations that Resident #1 was verbally and physically abused by staff members, including hitting, inappropriate touching, and removal of call bell. The facility was cited and required to submit a plan of correction.

Complaint #31052 was investigated. Allegations included verbal and physical abuse of Resident #1 by staff. The complaint was substantiated based on facility incident reports, hospital discharge summary, police involvement, and interviews.

Unannounced visits were made to Trinity Hill Care Center on October 26 and 27, 2021, by the Department of Public Health for the purpose of conducting a complaint investigation related to allegations of abuse.

The investigation found violations of Connecticut State regulations related to abuse allegations involving Resident #1. The facility failed to notify the Director of Nursing timely about the abuse allegations. A plan of correction was required to address systemic changes to prevent recurrence and ensure compliance.

Complaint investigation #31052 was conducted due to allegations that Resident #1 was abused by staff, including verbal abuse, physical abuse, and inappropriate touching. The complaint was substantiated with findings that the facility did not notify the Director of Nursing immediately as required.

An unannounced visit was made to Trinity Hill Care Center on June 17, 2021, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation related to complaint #30222.

The investigation found evidence of a mouse infestation in multiple areas of the facility, including resident rooms and common areas. Several residents reported being bitten by mice, and the facility's pest control measures were reviewed. The facility had implemented some pest control actions but had not fully resolved the issue.

Complaint #30222 triggered the investigation. The complaint involved reports of mice biting residents and inadequate pest control. The complaint was substantiated based on observations and interviews.

A COVID-19 Focused Survey and a complaint were conducted on 10/1/20 at Trinity Hill Care Center to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.

The facility failed to ensure the clinical record was complete for one sampled resident regarding fifteen minute checks as ordered by the physician. The facility also failed to ensure screening of visitors and staff for COVID-19 symptoms and proper mask usage was consistently performed and documented.

The complaint investigation included review of clinical records, observations, staff interviews, and facility policies related to infection control and resident monitoring. The complaint was substantiated based on findings of incomplete clinical documentation and inadequate infection control practices.

An unannounced visit was conducted to investigate an allegation of mistreatment and to perform a Covid-19 focused infection control survey at Trinity Hill Care Center.

The facility failed to ensure Resident #2 was free from abuse after a sexual encounter with Resident #1, who had an autoimmune disease. Additionally, the facility failed to transcribe a new medication order for Resident #2, resulting in missed doses of Seroquel for eight days.

The investigation was triggered by an allegation of mistreatment involving Resident #2. The facility was found to have failed to prevent a nonconsensual sexual encounter between Resident #1 and Resident #2. Resident #2 was unable to consent due to severe cognitive impairment. The facility also failed to transcribe a new medication order for Resident #2, leading to missed medication doses. The facility disputed the findings and requested an Informal Dispute Resolution.

A COVID-19 Focused Infection Control Survey and a complaint investigation were conducted on 9/23/2020 at Trinity Hill Care Center to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices and to investigate an allegation of mistreatment involving two residents.

The facility failed to ensure Resident #2 was free from abuse after an incident involving a non-consensual sexual encounter with Resident #1. Resident #2 was placed on constant observation and separated from Resident #1. Additionally, the facility failed to transcribe a new medication order for Resident #2 in accordance with policy, resulting in missed doses of Seroquel for 8 days.

The complaint investigation was triggered by an allegation of mistreatment involving Resident #2, who was found engaged in a non-consensual sexual encounter with Resident #1. Resident #2 was cognitively impaired and unable to consent. The facility placed Resident #2 on constant observation and separated the residents. The conservator was notified and antiviral treatment was ordered but delayed due to inability to reach the conservator for consent.

The visit was an unannounced routine inspection conducted on 9/23/20 for the purpose of conducting a COVID-19 focused survey and a complaint investigation (CT#28558).

Staffing was reviewed and found to meet Public Health Code requirements. PPE was sufficient and infection control practices were implemented in all areas. Findings were identified during the visit.

The visit included a complaint investigation referenced as #28558. The complaint investigation was part of the COVID-19 focused survey visit.

An unannounced visit was made to Trinity Hill Care Center on July 31, 2020, by representatives of the Facility Licensing and Investigations Section of the Department of Public Health to conduct an investigation and a COVID-19 focused infection control survey.

The facility was found to have multiple violations including failure to maintain a clean and homelike environment, failure to ensure cigarette ash receptacles were free from flammable materials, and failure to properly prepare food under sanitary conditions. Plans of correction were submitted for each violation with compliance dates in early September 2020.

Complaint CT #27337 was investigated during the visit.

A COVID-19 Focused Infection Control Survey and investigation was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including infection prevention and control practices to prevent COVID-19 transmission.

The facility was found deficient in maintaining a safe, clean, and homelike environment, including peeling handrails, cigarette ash receptacles containing flammable materials, unsafe exterior environment with combustible debris, and unsanitary food preparation conditions such as heavy dust and grease accumulation in kitchen vent hoods.

A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.

No deficiencies were cited as a result of this survey.

An unannounced visit was conducted at Trinity Hill Care Center by the Department of Public Health for a COVID-19 focused infection control survey.

The facility failed to ensure the use of specific PPE in accordance with infection control standards, including improper use and storage of Tyvek coveralls. The facility disputed the findings and requested an Informal Dispute Resolution.

An unannounced visit was conducted on April 20, 2020, by the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a COVID-19 Focused Survey.

The facility failed to ensure proper use of Personal Protective Equipment (PPE) and handwashing in accordance with infection control standards. Specifically, an LPN was observed wearing non-approved personal clothing under PPE and failing to follow proper donning and doffing procedures, which posed a breach in infection control practices.

A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, focusing on infection prevention and control practices to prevent COVID-19 transmission.

The facility failed to ensure proper use of Personal Protective Equipment (PPE), including proper donning and doffing and handwashing, as evidenced by an LPN wearing non-approved personal clothing and improper PPE handling after exiting a COVID-19 positive resident's room.

The visit was a revisit for the purpose of reviewing the implementation of the plan of correction submitted to the Department as a result of a prior violation letter dated 10/23/19.

No violations of the Public Health Code or Regulations of Connecticut State Agencies were identified during this visit. The facility was found to be in substantial compliance with all requirements.

The inspection was conducted as a complaint investigation triggered by complaints #26126 and #26238, involving allegations of abuse and failure to conduct thorough investigations and assessments.

The facility was found noncompliant with multiple regulations including failure to investigate abuse allegations thoroughly, inadequate monitoring and assessment of residents' conditions, failure to ensure proper laboratory testing and medication monitoring, and failure to conduct neurological checks after unwitnessed falls. Several residents had documented declines in condition that were not properly addressed or documented.

Complaint investigation #26126 and #26238 involved allegations of abuse and failure to conduct proper investigations and monitoring of residents. The complaints were substantiated with findings of noncompliance in multiple areas including abuse investigation, clinical assessments, medication monitoring, and neurological checks after falls.

Unannounced visits were made to the facility for the purpose of a certification survey, a licensure survey, and multiple investigations.

The facility was found deficient in multiple areas including failure to honor a resident's right to refuse hospice services, failure to review and document advance directives and code status, failure to notify physicians of resident refusals of ordered lab tests, failure to report and investigate alleged verbal abuse, failure to complete required MDS assessments for hospital discharges and readmissions, failure to follow physician orders for blood work and daily weights, failure to ensure timely physician visits, failure to maintain complete and accurate clinical records including CPR documentation, and failure to ensure timely urologist follow-up and catheter changes.

Unannounced visits were made to Trinity Hill Care Center for multiple investigations, a licensure and certification inspection, and complaint investigations.

The report details multiple violations related to resident care, including failure to honor hospice service refusals, failure to review advanced directives, failure to notify physicians of lab test refusals, failure to investigate abuse allegations, failure to complete MDS assessments, failure to follow physician orders, failure to secure medication rooms, and failure to maintain accurate clinical records. Plans of correction were submitted for each violation.

Complaints #23471, 23315, 23530 triggered investigations related to hospice care refusal, advanced directives, laboratory testing, abuse allegations, and other care concerns.

The inspection was conducted as a complaint investigation related to Complaint Investigation #24501, to assess violations of the General Statutes of Connecticut and regulations of Connecticut State Agencies.

The facility was found to have substantiated abuse and mistreatment of a resident by a housekeeper, including physical abuse and failure to report and supervise properly. Additional deficiencies were noted in clinical record documentation, care planning, and staff notification regarding resident conditions and medication management.

Complaint Investigation #24501 was substantiated. The investigation found abuse and mistreatment of a resident by a housekeeper, including physical abuse and failure to report. The facility was required to submit a plan of correction.

Unannounced visits were made to Trinity Hill Care Center on January 3, 4, 5, and 6, 2017 for the purpose of conducting an investigation and a licensing inspection, including complaint investigations.

Violations of the Regulations of Connecticut State Agencies and/or General Statutes of Connecticut were identified during the visits, including failures in dental assessments, medication storage and labeling, transcription of physician orders, and infection control. The facility was required to submit a plan of correction addressing these issues.

Complaint investigations #CT00020694, #21581, #21747, #21837 were conducted. Violations were substantiated and identified during the inspections.