Deficiencies (last 9 years)
Deficiencies (over 9 years)
13.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
136% worse than Connecticut average
Connecticut average: 5.6 deficiencies/year
Deficiencies per year
40
30
20
10
0
Census
Latest occupancy rate
122 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: May 20, 2025
Visit Reason
The inspection was conducted following complaints of resident-to-resident abuse and failure to ensure adequate supervision to prevent altercations resulting in injury.
Complaint Details
The complaint investigation involved allegations of resident-to-resident abuse. The facility was found to have failed to prevent a resident-to-resident altercation resulting in a resident sustaining a severe subdural hematoma. The facility did not substantiate abuse due to lack of willful intent but failed in supervision and care planning.
Findings
The facility failed to protect residents from abuse, specifically a resident-to-resident physical altercation causing serious injury including a subdural hematoma requiring hospitalization. The facility also failed to develop a comprehensive care plan for a resident on anticoagulants and failed to ensure timely physician order reviews for two residents.
Deficiencies (4)
Failure to protect residents from all types of abuse including physical abuse resulting in immediate jeopardy to resident health or safety.
Failure to develop and implement a complete care plan addressing bleeding risk for a resident on anticoagulant medications.
Failure to ensure adequate supervision to prevent resident-to-resident incidents resulting in injury.
Failure to ensure physician orders were reviewed, signed, and renewed at least every 60 days for residents.
Report Facts
BIMS score: 10
BIMS score: 5
Length of hospital stay after injury: 30
Days between physician order signatures: 127
Laceration size: 2
Medication dosage: 5
Medication dosage: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD #1 | Medical Director | Interviewed regarding the injury causation, physician order signing delays, and medical oversight. |
| DNS | Director of Nursing Services | Interviewed regarding facility's failure to substantiate abuse and care planning deficiencies. |
| RN #2 | MDS Coordinator | Interviewed about failure to create care plan for bleeding risk and electronic medical record system limitations. |
| APRN #1 | Advanced Practice Registered Nurse | Conducted neurological assessment and participated in care planning for Resident #3. |
Inspection Report
Plan of Correction
Census: 122
Deficiencies: 2
Date: Apr 14, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to ensure Resident #1 was free from physical abuse by Resident #2, including unprovoked slapping incidents.
Failure to meet required staffing levels for Licensed and Nurse Aides combined staffing hours on multiple days.
Report Facts
Census: 116
Census: 122
Census: 121
Staffing hours required: 251.72
Staffing hours actual: 238
Staffing hours below required: 13.72
Staffing hours required: 264.74
Staffing hours actual: 212
Staffing hours below required: 52.74
Staffing hours required: 262.57
Staffing hours actual: 226
Staffing hours below required: 36.57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Golas Markure | Supervising Nurse Consultant | Contact for questions regarding violations and instructions |
| Director of Nurses | Director of Nurses | Responsible for plan of correction |
| Administrator | Administrator | Responsible for monitoring and ensuring compliance with plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 14, 2025
Visit Reason
The inspection was conducted following a complaint investigation into an incident where Resident #2 was witnessed slapping Resident #1 in the facility.
Complaint Details
The complaint investigation was substantiated by witness statements and facility documentation. Resident #2 had prior altercations and was on a waitlist for psychiatric evaluation. Resident #2 was placed on 1:1 monitoring and followed by psychiatric services.
Findings
The facility failed to ensure Resident #1 was free from physical abuse when Resident #2 slapped Resident #1 twice. Resident #2 was placed on one-to-one monitoring and transferred to the hospital for evaluation. The facility did not consider the contact willful but acknowledged physical contact occurred. The facility's abuse policy defines physical abuse and prohibits abuse by any individual.
Deficiencies (1)
Failure to protect Resident #1 from physical abuse by Resident #2 who slapped Resident #1 twice.
Report Facts
Date of incident: Mar 25, 2025
Date of care plan for Resident #1: Mar 26, 2025
Date of care plan for Resident #2: Feb 13, 2025
Prior altercation dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Assistant (NA #1) | Witnessed Resident #2 slapping Resident #1 twice | |
| Registered Nurse (RN #1) | Interviewed regarding the incident and medication adjustments | |
| Social Worker (SW #1) | Interviewed regarding Resident #2's psychiatric status | |
| Social Worker (SW #2) | Interviewed regarding Resident #2's psychiatric status | |
| Director of Nursing Services (DNS) | Interviewed regarding the incident and facility response | |
| Administrator | Interviewed regarding the incident and facility response | |
| Lab Technician (Lab Tech #1) | Reported the incident but refused to provide a witness statement |
Inspection Report
Monitoring
Census: 122
Capacity: 134
Deficiencies: 1
Date: Dec 27, 2024
Visit Reason
The visit was a desk audit and monitoring inspection to review the implementation of the Plan of Correction for previously identified violations.
Findings
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.
Deficiencies (1)
Violations #1a, 2a, 3a, 3b, 3c, 3d, 3e, 3f, 3g, 4a, 5a, 5b, 5c, 5d, 6a, 7a, 8a, 9a, 10a, 11a, 12a, 12b, 12c, 13a, 13b, 13c, and 14a were identified as corrected.
Report Facts
Licensed Bed Capacity: 134
Census: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosemary Harvey | Director of Nursing | Notified by telephone regarding correction of violations |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 134
Deficiencies: 0
Date: Nov 8, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to complaint investigations #41691, #41701, and #41471.
Complaint Details
Complaint investigations #41691, #41701, and #41471 were reviewed; no violations were substantiated.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Report Facts
Complaint investigations referenced: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| George Kingston | Administrator | Personnel contacted during inspection |
| Rosemarie Harvey | Director of Nursing | Personnel contacted during inspection |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Oct 29, 2024
Visit Reason
The inspection was conducted based on complaints and incidents involving resident-to-resident abuse, failure to implement admission policies, incomplete care plans following incidents, and concerns about medication administration and medical record keeping.
Complaint Details
The complaint investigation was triggered by multiple incidents of resident-to-resident abuse including physical altercations resulting in injuries, failure to implement admission policies, and concerns about medication administration and medical record keeping. The facility did not substantiate some incidents as abuse due to resident confusion.
Findings
The facility failed to ensure residents were free from abuse, failed to update care plans following incidents, did not complete required admission paperwork or notify conservators, failed to verify admission medication orders timely, and did not maintain complete and accessible medical records including observation flowsheets and pharmacy recommendations.
Deficiencies (5)
Failure to protect residents from abuse including physical altercations between residents resulting in injuries.
Failure to update resident care plans following incidents of abuse and altercations.
Failure to ensure admission paperwork was completed and conservators were notified for a conserved resident.
Failure to verify admission medication orders prior to administration and failure to have physician orders for central line catheter care.
Failure to maintain complete, accurate, and accessible medical records including missing observation flowsheets and pharmacy review documentation.
Report Facts
Skin tear size: 1
Skin tear size: 0.5
Medication doses: 2
Medication doses: 1500
Medication doses: 900
Medication doses: 500
Medication doses: 100
Medication doses: 21
Medication doses: 10
Medication doses: 130
Medication doses: 50
Medication doses: 3
Medication doses: 5
Medication doses: 24
Medication doses: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Witnessed Resident #32 throw a chair at Resident #30 causing injury |
| LPN #10 | Licensed Practical Nurse | Witnessed Resident #112 pour urine on Resident #31 and assault him/her |
| RN #6 | Registered Nurse | Responded to Resident #112 assaulting Resident #31 |
| SW #1 | Social Work Director | Responsible for updating resident care plans following incidents |
| SW #2 | Social Worker | Responsible for updating resident care plans and admission paperwork |
| DNS | Director of Nursing Services | Oversaw care plan reviews and investigations |
| APRN #1 | Advanced Practice Registered Nurse | Verified medication orders on 10/14/24 for Resident #377 |
| RN #3 | Nursing Supervisor | Did not verify admission medication orders on 10/11/24 |
| LPN #2 | Infection Preventionist | Did not verify admission medication orders on 10/11/24 |
| ADNS | Assistant Director of Nursing Services | Did not verify admission medication orders on 10/11/24 |
| MD #1 | Physician | Did not verify admission medication orders on 10/11/24 |
Inspection Report
Complaint Investigation
Deficiencies: 14
Date: Oct 29, 2024
Visit Reason
The inspection was conducted to investigate multiple complaints related to resident rights, abuse, medication administration, dental services, and infection control at Trinity Hill Care Center.
Complaint Details
The investigation was complaint-driven, focusing on allegations of inadequate response to resident grievances, abuse incidents, medication errors, lack of dental care, and infection control deficiencies.
Findings
The facility failed to provide documentation of responses to resident council grievances, ensure accurate physician orders for code status, prevent resident-to-resident abuse, implement admission policies including conservator notification, verify admission medication orders, provide timely pain management, ensure dental services were provided, maintain proper food labeling, safeguard resident medical records, and conduct required water management meetings.
Deficiencies (14)
Failed to provide documentation of the facility's response to resident council grievances regarding staff behavior and resident rights.
Failed to ensure physician's order accurately reflected resident's chosen code status (DNR vs full code).
Failed to protect residents from abuse including multiple resident-to-resident altercations resulting in injuries and inadequate investigation and documentation.
Failed to implement admission policy including obtaining conservator consent and completing required admission paperwork.
Failed to develop and revise care plans timely following incidents of abuse and after admission and quarterly assessments.
Failed to verify admission medication orders and ensure physician orders for central line catheter care were present and accurate.
Failed to ensure physician's order was in place directing oxygen therapy for a resident using oxygen.
Failed to administer pain medication in a timely manner resulting in resident distress and a fall.
Failed to ensure access to emergency supply medication and maintain proper controlled substance accountability including secure storage and reconciliation.
Failed to ensure pharmacy recommendations were reviewed by the provider and present in the resident clinical chart; lacked policy for processing pharmacy recommendations.
Failed to ensure resident was seen by a dentist/hygienist despite orders and complaints of dental pain.
Failed to ensure food items were appropriately labeled and dated when opened or stored and removed once expired.
Failed to maintain complete, accurate, and readily accessible resident medical records including missing observation flowsheets and conservator paperwork.
Failed to conduct the annual water management plan meeting as required by facility policy and contract.
Report Facts
Resident-to-resident altercation dates: 3
Medication administration delay: 2.5
Number of pharmacy drug regimen reviews: 4
Number of dental visits by dentist: 6
Number of dental visits by hygienist: 3
Number of yellow Controlled Substance Disposition Record sheets: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Charge Nurse | Witnessed resident-to-resident altercation involving chair throwing. |
| APRN #1 | Advanced Practice Registered Nurse | Reviewed and signed advance directives and medication orders; acknowledged errors in code status orders. |
| LPN #3 | Licensed Practical Nurse | Involved in delayed pain medication administration incident. |
| NA #1 | Nursing Assistant | Reported resident pain and notified nurse multiple times during medication delay incident. |
| Director of Maintenance | Identified failure to conduct annual water management plan meeting. | |
| Food Service Director | Identified unlabeled food items in kitchen. | |
| Social Worker #2 | Designated Social Worker | Responsible for admission paperwork and care plan updates; identified missing paperwork. |
| Regional Clinical Director | Discussed pharmacy recommendation process and care plan deficiencies. | |
| ADNS | Assistant Director of Nursing Services | Discussed medication order verification and controlled substance accountability. |
| DNS | Director of Nursing Services | Oversaw care plan reviews, medication order follow-up, and controlled substance audits. |
Inspection Report
Renewal
Census: 115
Capacity: 134
Deficiencies: 0
Date: Oct 21, 2024
Visit Reason
The inspection was conducted as a licensing inspection for renewal purposes and included review of complaint investigations #39533 and #40051.
Findings
No violations of the General Statutes of Connecticut or regulations were identified at the time of this inspection.
Report Facts
Licensed Bed Capacity: 134
Census: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Schumann | Survey Team Leader | Named as Survey Team Leader and report submitter |
| George Kingston | Administrator | Personnel contacted during inspection |
| Rosemary Harvey | Director of Nursing Services | Personnel contacted during inspection |
Inspection Report
Renewal
Census: 131
Capacity: 134
Deficiencies: 1
Date: Apr 11, 2024
Visit Reason
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.
Findings
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.
Deficiencies (1)
Violation #1 identified in previous inspection
Report Facts
Licensed Bed Capacity: 134
Census: 131
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yong Chandell | Administrator | Notified via telephone that all violations were corrected |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 23, 2024
Visit Reason
The inspection was conducted following a complaint investigation regarding Resident #1's rights being potentially violated by restricting the resident from leaving a secured unit without staff escort.
Complaint Details
The complaint investigation was substantiated as the facility restricted Resident #1's ability to leave the secured unit independently due to an investigation of alleged theft of personal items by Resident #1.
Findings
The facility failed to ensure Resident #1's rights by not permitting the resident to leave the secured unit without supervision, despite prior physician orders and care plans supporting more independence. The resident's safety level was changed due to an investigation of alleged theft, resulting in restricted movement and causing distress to the resident.
Deficiencies (1)
Failed to ensure Resident Rights by restricting Resident #1 from leaving the secured unit without escort contrary to care plan and physician orders.
Report Facts
Days restricted: 15
Safety Levels: 3
Safety Levels: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed Resident #1 upset due to activity level suspension on 12/27/2023. |
| APRN #3 | Advanced Practice Registered Nurse | Conducted psychiatric assessments of Resident #1 related to behavioral concerns and restrictions. |
| SW #1 | Social Worker | Spoke with Resident #1 and managed safety level changes related to the investigation. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 30, 2023
Visit Reason
The inspection was conducted to review the facility's compliance with maintaining complete and accurate medical records, specifically regarding the offering and refusals of support services for residents.
Findings
The facility failed to maintain complete and accurate medical records for Resident #2, specifically lacking documentation of offering and refusals to attend the substance use recovery program groups. Interviews with staff confirmed the absence of required documentation.
Deficiencies (1)
Failed to maintain a complete and accurate medical record to include offering and refusals of support services for Resident #2.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Work (SW #2) | Interviewed regarding Resident #2's refusal to attend Recovery Program groups and lack of documentation. | |
| Director of Nursing (DON) | Interviewed regarding documentation requirements for resident refusals. | |
| Clinical Director | Interviewed and reviewed medical records confirming lack of documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 28, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding medication administration and blood sugar monitoring for Resident #1, specifically the failure to administer insulin and perform blood sugar monitoring as ordered by the physician.
Complaint Details
Complaint investigation focused on medication administration and blood sugar monitoring for Resident #1. The complaint was substantiated with findings of failure to administer insulin and perform blood sugar monitoring as ordered.
Findings
The facility failed to ensure that Resident #1 received the prescribed Lantus insulin and that blood sugar monitoring was performed as ordered. The medication order was not transcribed onto the Medication Administration Record (MAR), and fingerstick blood sugar monitoring was not documented or performed as required. Interviews with nursing staff and the Director of Nursing (DON) confirmed these failures and the lack of a double-check process for medication orders.
Deficiencies (2)
Failure to transcribe and administer Lantus insulin as ordered for Resident #1.
Failure to perform and document fingerstick blood sugar monitoring twice daily as ordered.
Report Facts
Insulin dosage: 16
Fingerstick blood sugar monitoring frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | RN Supervisor | Named in relation to failure to transcribe insulin order onto MAR |
| DON | Director of Nursing | Interviewed regarding medication administration failures and documentation |
| LPN #3 | Scheduled nurse during evening shift when fingerstick monitoring was not performed; interview not obtained |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 134
Deficiencies: 1
Date: Aug 28, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure insulin was administered and blood sugar monitoring was performed according to physician orders for Resident #1 with diabetes.
Report Facts
Licensed Bed Capacity: 134
Census: 106
Complaint Number: 35239
Units of Insulin Ordered: 16
Date of Inspection: Aug 28, 2023
Plan of Correction Submission Deadline: Sep 23, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yong Crandall | Administrator | Personnel contacted during the inspection. |
| Maureen Golas Markure | Supervising Nurse Consultant | Signed the violation letter and correspondence. |
| RN #1 | Identified as the RN supervisor involved in the medication administration process for Resident #1. | |
| DON | Director of Nursing | Interviewed regarding medication administration and transcription errors. |
| LPN #3 | Nurse scheduled during evening shift on 1/3/2023, involved in medication administration review. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 22, 2023
Visit Reason
The inspection was conducted based on complaints from Resident #1 regarding rodent issues in the room and the front receptionist not answering phone calls.
Complaint Details
Resident #1 complained of mice issues in the room and the front receptionist not answering phone calls. The complaint regarding mice was substantiated by observations of rodent droppings. Resident #1 also complained that calls to the facility phone number went straight to voicemail.
Findings
The facility failed to maintain a clean and sanitary environment as evidenced by rodent droppings found in Resident #1's room. Additionally, the facility failed to keep the resident's call bell within reach, and Resident #1 reported difficulty in reaching staff by phone, with calls going directly to voicemail.
Deficiencies (2)
Failure to maintain a clean and sanitary environment with rodent droppings found in Resident #1's room.
Failure to keep Resident #1's call bell within reach when an alternative option was not in use.
Report Facts
Date of grievance: Apr 17, 2023
Date of care plan meeting: May 1, 2023
Frequency of exterminator visits: 1
Check frequency: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Charge Nurse | Identified Resident #1 calls for help by calling the facility on his/her cell phone |
| Administrator | Interviewed regarding rodent droppings and call bell issues; arranged cleaning and follow-up with phone company |
Inspection Report
Deficiencies: 4
Date: Mar 6, 2023
Visit Reason
The inspection was conducted to review the facility's compliance with medication administration documentation policies, specifically focusing on medication administration records (MAR) for residents with substance abuse and other medical conditions.
Findings
The facility failed to document administration of critical medications including Narcan, Oxycodone, and Insulin Lispro on the medication administration record (MAR) for multiple residents, despite administration occurring. Interviews with nursing staff confirmed medication administration but acknowledged documentation omissions due to event urgency.
Deficiencies (4)
Failure to document administration of Narcan for suspected opioid overdose on the MAR for Resident #2 on 9/11/22.
Failure to document administration of Oxycodone on the MAR for Resident #2 for the entire month of September 2022.
Failure to document administration of Insulin Lispro sliding scale doses on the MAR for Resident #2 on 10/31/22.
Failure to document administration of Narcan for suspected opioid overdose on the MAR for Resident #3 on 9/3/22.
Report Facts
Medication doses: 2
Medication doses: 12
Medication doses: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Administered Narcan to Resident #2 and omitted documentation due to rush of event |
| RN #3 | Registered Nurse | Administered Insulin Lispro to Resident #2 and failed to document administration on MAR |
| RN #2 | Registered Nurse | Administered Narcan to Resident #3 and documented clinical observations |
| Director of Nurses | Director of Nursing | Interviewed regarding medication documentation policies |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Apr 14, 2022
Visit Reason
The inspection was conducted as an annual survey of Trinity Hill Care Center to assess compliance with regulatory requirements related to resident environment, abuse reporting, resident rights, infection control, and care practices.
Findings
The facility was found deficient in maintaining a clean and homelike environment, timely reporting of alleged misappropriation of resident property, permitting residents to return after hospitalization especially with active COVID-19 infections, conducting RN assessments upon significant resident status changes, and completing behavior monitoring for residents on psychotropic medications. Deficiencies were generally of minimal harm with few residents affected.
Deficiencies (5)
Failed to provide and maintain a clean, sanitary and homelike environment including holes in walls, rodent droppings, and stained ceiling tiles.
Failed to report an allegation of misappropriation of resident property to the State Agency.
Failed to allow residents to return to the facility after hospitalization and failed to readmit residents with active COVID-19 infections.
Failed to ensure a Registered Nurse assessment was conducted and documented when a resident exhibited a significant change in status.
Failed to complete behavior monitoring in accordance with facility policy for residents receiving antipsychotic medications.
Report Facts
30-day involuntary discharge notice: 30
Amount of missing money reported: 3000
Dates of observations: 3
Asenapine patch dosage: 3.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reported significant change in Resident #1's status and notified Nursing Supervisor and physician |
| RN #2 | Registered Nurse | Notified of Resident #1's status change but unable to document assessment due to lack of EHR access |
| Director of Maintenance | Aware of environmental deficiencies and responsible for repairs | |
| Social Worker #1 | Social Worker | Provided grievance form to Resident #2 and involved in discharge process |
| Administrator | Facility Administrator | Interviewed regarding Resident #2's grievance and discharge process |
| LPN #2 | Infection Preventionist | Identified environmental rounds documentation and department responsibilities |
| President of Business Development | VP | Provided information on COVID-19 resident transfers and facility challenges |
| Director of Nursing | DON | Discussed nursing staff access to EHR and expectations for assessments and behavior monitoring |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 144
Deficiencies: 1
Date: Oct 27, 2021
Visit Reason
Unannounced visits were made to Trinity Hill Care Center for the purpose of conducting a complaint investigation related to allegations of abuse.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Resident #1 was verbally abused by an LPN and physically abused by staff including inappropriate touching and removal of call bell.
Report Facts
Licensed Bed Capacity: 144
Census: 112
Inspection Dates: 2
Plan of Correction Due Date: Dec 2, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yong Crandall | Administrator | Contacted during inspection |
| Shantel Viera | DNS | Contacted during inspection and responsible for plan of correction |
| Maureen Golas-Markure | Supervising Nurse Consultant | Author of the complaint investigation letter |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 144
Deficiencies: 1
Date: Oct 26, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to follow standards of practice related to abuse allegations and timely notification to appropriate staff.
Report Facts
Licensed Bed/Bassinet Capacity: 144
Census: 112
Inspection Dates: 2021-10-26 and 2021-10-27
Plan of Correction Due Date: Dec 2, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yong Crandall | Administrator | Named as personnel contacted during inspection |
| Shantel Viera | Director of Nursing Services (DNS) | Named as personnel contacted during inspection and responsible for plan of correction |
| Maureen Golas-Markure | Supervising Nurse Consultant | Author of complaint investigation report and correspondence |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 17, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Presence of mice observed in the nourishment room, nurse's station, and resident rooms on multiple dates, with residents bitten by mice and inadequate pest control measures.
Report Facts
Dates mice observed: 2/18/2021, 3/12/2021, and dates between 3/4 and 4/18/2021
Resident BIMS scores: 15
Number of alternating resident rooms treated weekly: 12
Number of black boxes placed for bait: 1
Number of white sticky pads: 2
Plan of correction audit period: 3
Plan of correction audit start date: Audits to commence on 8/27/21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Golas Markure | Supervising Nurse Consultant | Author of the notice letter and contact for questions regarding violations |
| Yong Crandall | Administrator | Administrator of Trinity Hill Care Center, involved in interviews and responsible for pest control follow-up |
| Director of Maintenance | Identified as aware of the mouse problem and responsible for pest control measures such as placing bait boxes and sticky sheets | |
| Person #1 | Pest control representative | Provided information about pest control visits and observations of mice droppings |
| DNS | Director of Nursing Services, aware of mouse problem and pest control company visits |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 1, 2020
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Resident Records - Identifiable Information and clinical record completeness for fifteen minute checks was not met for Resident #1.
Infection Prevention & Control program deficiencies including failure to screen visitors and staff properly for COVID-19 and failure to ensure staff wore masks correctly.
Report Facts
Dates of clinical documentation: 15
Dates of monitoring flow sheet: 12
Dates of flow sheet review: 14
Plan of correction completion date: Nov 30, 2020
Dates of observations: 1
Duration of audits: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADNS) | Interviewed on 10/1/20 regarding responsibility for ensuring checks were conducted and documented |
| Director of Nursing | Director of Nursing (DON) | Interviewed on 10/1/20 regarding staff and visitor screening procedures |
| Security Guard #1 | Security Guard | Interviewed on 10/1/20 regarding screening questions for surveyors |
| RN #1 | Registered Nurse | Interviewed on 10/1/20 regarding mask wearing policy |
| Licensed Practical Nurse #4 | Licensed Practical Nurse (Infection Preventionist) | Interviewed on 10/1/20 regarding mask wearing expectations in kitchen |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 23, 2020
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to ensure Resident #2 was free from abuse following a nonconsensual sexual encounter with Resident #1.
Failure to transcribe a new medication order for Resident #2, resulting in missed administration of Seroquel 25 mg three times daily for 8 days.
Report Facts
Days medication not administered: 8
Medication dosage: 25
Audit duration: 30
Audit duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Ruot | Supervising Nurse Consultant | Author of the inspection report and contact for questions regarding violations. |
| LPN #1 | Observed and reported the sexual encounter between Resident #1 and Resident #2. | |
| Director of Nursing | Director of Nursing | Interviewed regarding failure to transcribe medication order for Resident #2 and responsible for plan of correction. |
| RN #1 | Interviewed about transcription of medication orders during busy period. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 23, 2020
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to ensure Resident #2 was free from abuse following a non-consensual sexual encounter with Resident #1.
Failure to transcribe a new medication order for Resident #2, resulting in missed administration of Seroquel for 8 days.
Report Facts
Days medication not administered: 8
Date of survey: Sep 23, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed the non-consensual sexual encounter and reported the incident. |
| Director of Nursing | Director of Nursing | Acknowledged failure to transcribe medication order due to charge nurse absence. |
| RN #1 | Registered Nurse | Did not remember transcribing Resident #2's new medication order on 9/15/20. |
| Person #1 | Conservator | Provided consent for antiviral treatment and opposed sexual relationship if medically contraindicated. |
Inspection Report
Routine
Census: 123
Capacity: 144
Deficiencies: 0
Date: Sep 23, 2020
Visit Reason
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).
Complaint Details
The visit included a complaint investigation referenced as #28558. The complaint investigation was part of the COVID-19 focused survey visit.
Findings
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.
Report Facts
Licensed Bed: 144
Census: 123
Employees mentioned
| Name | Title | Context |
|---|---|---|
| George Kingston | Administrator | Personnel contacted during the inspection |
| Hyacinth Vaughn | Acting Director of Nursing | Personnel contacted during the inspection |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jul 31, 2020
Visit Reason
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.
Complaint Details
Complaint CT #27337 was investigated during the visit.
Findings
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.
Deficiencies (3)
Hand railing in the resident's hallway was peeling with laminate hanging; maintenance was notified to repair.
Cigarette ash receptacles were overflowing with flammable materials including paper, plastic wrappers, and tissues.
Heavy accumulation of dust and grease in the kitchen and on the kitchen vent hood; improper food preparation conditions observed.
Report Facts
Date of inspection: Jul 31, 2020
Compliance date for Plan of Correction #1: Sep 1, 2020
Compliance date for Plan of Correction #2: Sep 1, 2020
Compliance date for Plan of Correction #3: Sep 1, 2020
Number of cigarette ash receptacles observed: 3
Number of residents smoking: 4
Number of staff smoking: 2
Time of hand railing observation: 1100
Time of cigarette ash receptacles observation: 1000
Time of kitchen observation: 1010
Time of food service director interview: 1015
Time of administrator interview: 1130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Ruot | Supervising Nurse Consultant | Signed letter regarding violations and plan of correction |
| Director of Housekeeping | Interviewed about hand railing condition | |
| Administrator | Interviewed about cigarette ash receptacles | |
| Food Service Director | Interviewed about kitchen sanitation and cleaning schedule | |
| Maintenance Supervisor | In-serviced on importance of maintaining handrails and smoking receptacles |
Inspection Report
Abbreviated Survey
Deficiencies: 4
Date: Jul 31, 2020
Visit Reason
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.
Findings
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.
Deficiencies (4)
Failed to maintain a clean and homelike environment; hand railing in resident hallway was peeling with laminate hanging.
Failed to ensure cigarette ash receptacles were free from flammable materials; ash receptacles were overflowing with paper, plastic wrappers, and tissues.
Exterior environment had combustible materials and debris throughout the rear of the building, including trash, wooden pallets, old resident equipment, and a propane tank.
Failed to properly prepare food under sanitary conditions; heavy accumulation of dust and grease in kitchen vent hood.
Report Facts
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Housekeeping | Interviewed regarding peeling handrails and cleaning practices | |
| Maintenance Supervisor | In-serviced on importance of maintaining handrails and smoking receptacles | |
| Administrator | Interviewed regarding cigarette ash receptacles and responsible for plan of correction | |
| Food Service Director | Interviewed regarding kitchen cleaning schedule and vent hood sanitation |
Inspection Report
Routine
Census: 118
Capacity: 144
Deficiencies: 0
Date: May 29, 2020
Visit Reason
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.
Findings
No deficiencies were cited as a result of this survey.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 13, 2020
Visit Reason
An unannounced visit was conducted at Trinity Hill Care Center by the Department of Public Health for a COVID-19 focused infection control survey.
Findings
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.
Deficiencies (1)
Failure to ensure use of specific PPE was implemented in accordance with infection control standards and facility policies, including staff utilizing Tyvek coveralls for COVID positive residents and storage of coveralls on a hanging rack.
Report Facts
Date of inspection observation: May 13, 2020
Date of interview: May 13, 2020
Number of Tyvek coveralls stored: 3
Plan of correction submission deadline: Jun 7, 2020
Plan of correction completion date: Jul 10, 2020
Audit duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Vermont-Hollis | Supervising Nurse Consultant | Signed letter regarding violations and plan of correction instructions |
| Director of Nursing | Responsible for plan of correction implementation |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 20, 2020
Visit Reason
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.
Findings
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.
Deficiencies (1)
Failure to ensure proper Personal Protective Equipment (PPE) use, including donning and doffing, and failure to ensure handwashing was conducted according to infection control standards.
Report Facts
Observation time: 9.25
Observation time: 9.4
Observation time: 9.42
Plan of correction completion date: Jun 30, 2020
Plan of correction submission deadline: May 14, 2020
Plan of correction training completion date: May 27, 2020
Audit duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Ruot | Supervising Nurse Consultant | Author of the report and representative of Facility Licensing and Investigations Section |
| LPN #1 | Observed failing to properly don and doff PPE and handwashing; subject of infection control deficiency | |
| Director of Nursing | DNS | Interviewed regarding PPE and infection control practices; responsible for plan of correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 20, 2020
Visit Reason
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.
Findings
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.
Deficiencies (1)
Failure to ensure proper Personal Protective Equipment (PPE) use, including donning, doffing, and handwashing in accordance with infection control standards and facility policies.
Report Facts
Completion date for plan of correction: Jun 30, 2020
In-service completion date: May 27, 2020
Audit duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Identified for improper PPE use and handwashing during care of COVID-19 positive resident |
| Director of Nursing | Director of Nursing | Observed and directed corrective actions regarding PPE use and infection control |
| Corporate Nurse #1 | Corporate Nurse | Provided infection control education to LPN #1 following surveyor observation |
Inspection Report
Follow-Up
Census: 128
Capacity: 144
Deficiencies: 0
Date: Nov 22, 2019
Visit Reason
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.
Findings
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.
Report Facts
License Capacity: 144
Census: 128
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dennis Billings | Administrator | Personnel contacted during inspection |
| Rose Marchion | RN DNS | Personnel contacted during inspection |
| Kelly Madden | RN | Report submitted by |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 144
Deficiencies: 5
Date: Sep 19, 2019
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (5)
Failure to conduct a thorough investigation after an allegation of abuse was reported.
Failure to conduct comprehensive assessments and monitor resident's decline in food and fluid intake.
Failure to ensure pharmacist's recommendations for laboratory testing were acted upon.
Failure to ensure specific laboratory testing was obtained at the time the order was written and then in six months as per physician's order.
Failure to provide documentation to ensure neurological checks were conducted after unwitnessed falls.
Report Facts
Licensed Bed Capacity: 144
Census: 135
Complaint Numbers: 2
Plan of Correction Submission Deadline: Plan of correction to be submitted by November 2, 2019.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dennis Billings | Administrator | Named in relation to the inspection and findings. |
| Karen Gworek | Supervising Nurse Consultant | Signed the important notice letters and involved in communication regarding deficiencies. |
| Director of Nursing | Interviewed regarding abuse allegations and resident care findings. | |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding resident care and observations. |
| Advanced Practice Registered Nurse #1 | Advanced Practice Registered Nurse | Interviewed regarding resident assessments and care. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding resident care and documentation. |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding bloodwork and resident care. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding neurological checks after falls. |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding resident condition changes and neurological checks. |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Jan 9, 2019
Visit Reason
Unannounced visits were made to the facility for the purpose of a certification survey, a licensure survey, and multiple investigations.
Findings
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.
Deficiencies (9)
Failure to honor Resident #54's right to refuse hospice services after initiation.
Failure to review and document advance directives and code status for multiple residents.
Failure to notify physician when Resident #124 refused ordered laboratory blood work and failure to obtain vital signs as ordered.
Failure to report an allegation of verbal abuse involving Resident #5 to the State Agency and failure to investigate the incident.
Failure to complete discharge and re-entry MDS assessments for Resident #542 after hospitalizations.
Failure to follow physician orders for blood work and daily weights for Resident #124 and Resident #141 respectively.
Failure to provide appropriate care for Resident #118 with a suprapubic catheter by ensuring timely urologist visits and catheter changes.
Failure to ensure timely physician visits for multiple residents.
Failure to maintain complete and accurate clinical records including CPR documentation for Resident #142.
Report Facts
Weight gain: 37
Weight gain: 16
Blood pressure: 52
Date: Jan 2, 2019
Date: Jan 9, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD #1 | Physician | Named in hospice services refusal finding |
| LPN #2 | Licensed Practical Nurse | Named in hospice services refusal finding |
| Person #1 | Resident's representative in hospice services refusal finding | |
| DNS | Director of Nursing Services | Named in hospice services refusal and advance directives findings |
| APRN #1 | Advanced Practice Registered Nurse | Named in advance directives and lab work findings |
| LPN #4 | Licensed Practical Nurse | Named in advance directives and weight documentation findings |
| RN #3 | Registered Nurse | Named in lab work and physician visit findings |
| NA #4 | Nurse Aide | Named in verbal abuse allegation |
| MD #2 | Physician | Named in physician visit findings |
Inspection Report
Plan of Correction
Deficiencies: 15
Date: Jan 9, 2019
Visit Reason
Unannounced visits were made to Trinity Hill Care Center for multiple investigations, a licensure and certification inspection, and complaint investigations.
Complaint Details
Complaints #23471, 23315, 23530 triggered investigations related to hospice care refusal, advanced directives, laboratory testing, abuse allegations, and other care concerns.
Findings
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.
Deficiencies (15)
Failed to honor Resident #54's right to refuse hospice services after initiation.
Failed to review advanced directives and ensure physician orders reflected residents' choices.
Failed to notify physician that laboratory testing and pulse oximetry were not completed as ordered for Resident #124.
Failed to identify and/or report a potential incident involving mistreatment for Resident #5.
Failed to investigate a potential incident involving mistreatment for Resident #5.
Failed to ensure MDS assessment was completed for resident discharge and entry for Resident #542.
Failed to follow physician orders for obtaining bloodwork and daily weights for Residents #124 and #141.
Failed to provide appropriate care for Resident #118 with a supra-pubic catheter.
Failed to review and/or sign monthly physician orders in a timely manner for Resident #142.
Failed to ensure timely physician visits for multiple residents.
Failed to secure medication room doors and medication carts properly.
Failed to ensure complete and accurate clinical records for Resident #142.
Failed to ensure clinical record completeness for Resident #542 related to discharge/reentry assessments.
Failed to update care plan following unwitnessed falls for Resident #543.
Failed to notify physician when Resident #543 refused transfer to Emergency Department.
Report Facts
Complaint numbers: 3
Residents reviewed: 15
Compliance date: Feb 20, 2019
Audit duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judy Birtwistle | Supervising Nurse Consultant | Signed the initial notice letter |
| George Kingston | Administrator | Named as facility administrator in the notice |
| RN #3 | Registered Nurse | Interviewed regarding laboratory testing and abuse investigations |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding resident respiratory status and refusal to transfer |
| APRN #1 | Advanced Practice Registered Nurse | Interviewed regarding laboratory testing and resident care |
| RN #4 | Registered Nurse | Identified as nursing supervisor for medication cart area |
Inspection Report
Routine
Deficiencies: 10
Date: Jan 9, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, advanced directives, physician visits, clinical care, and documentation.
Findings
The facility was found deficient in multiple areas including failure to honor a resident's right to refuse hospice services, incomplete review and documentation of advance directives, failure to notify physicians of resident refusals of ordered tests, failure to report and investigate alleged abuse, incomplete MDS assessments, failure to follow physician orders for bloodwork and weights, inadequate care for a resident with a suprapubic catheter, untimely physician visits, and incomplete clinical records related to a resident's death.
Deficiencies (10)
Failed to honor Resident #54's right to refuse hospice services after initiation.
Failed to review and document advance directives and code status for multiple residents.
Failed to notify physician that Resident #124 refused laboratory blood work testing.
Failed to identify and report potential verbal abuse incident involving Resident #5.
Failed to investigate alleged mistreatment of Resident #5.
Failed to complete discharge and entry MDS assessments for Resident #542.
Failed to follow physician orders for bloodwork and daily weights for Residents #124 and #141.
Failed to provide appropriate care for Resident #118 with suprapubic catheter including timely physician visits and catheter changes.
Failed to ensure timely physician visits for multiple residents.
Failed to maintain complete and accurate clinical records for Resident #142 including documentation of CPR and code status.
Report Facts
Deficiencies cited: 10
Weight gain: 37
Weight gain: 16
Blood pressure readings: 52
Lasix dosage: 40
Augmentin dosage: 875
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD #1 | Physician | Involved in hospice care decisions and unaware of resident's wish to discontinue hospice |
| Person #1 | Resident's Representative | Notified about hospice services and resident's wishes |
| LPN #2 | Licensed Practical Nurse | Notified hospice agency about resident's wish to discontinue hospice |
| DNS | Director of Nursing Services | Interviewed regarding hospice discontinuation, abuse incident, and laboratory test refusals |
| RN #2 | Registered Nurse | Completed SBAR note on Resident #124's edema and blood work refusal |
| APRN #1 | Advanced Practice Registered Nurse | Ordered blood work and antibiotics for Resident #124 and Resident #118 |
| RN #3 | Registered Nurse | Interviewed about incomplete blood work and untimely physician visits |
| LPN #4 | Licensed Practical Nurse | Interviewed about daily weights and advance directives |
| MD #2 | Physician | Interviewed about delayed physician visits and resident care |
| Resident #5 | Reported verbal mistreatment by Nurse Aide #4 |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 144
Deficiencies: 5
Date: Dec 6, 2018
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (5)
Substantiated abuse and mistreatment of a resident by a housekeeper, including physical abuse and failure to report.
Failure to ensure accurate and complete clinical record documentation and care planning for residents.
Failure to notify physicians timely regarding changes in resident conditions and medication needs.
Failure to properly monitor and supervise residents at risk for unauthorized leave or elopement.
Failure to maintain and monitor the wander guard system effectively.
Report Facts
Licensed Bed Capacity: 144
Census: 143
Inspection Dates: 2018-12-06 to 2018-12-10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| George Kingston | Administrator | Named as personnel contacted during the inspection and signatory on related documents. |
| Cheryl Davis | Supervising Nurse Consultant | Signed the complaint investigation letter. |
| Housekeeper #1 | Named in abuse findings related to physical mistreatment of a resident. | |
| RN #1 | Registered Nurse | Involved in care and documentation related to the resident abuse and medication administration. |
| RN #2 | Registered Nurse | Involved in care planning and clinical record review. |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding resident care and medication administration. |
| Advanced Practice Registered Nurse #1 | APRN | Interviewed regarding pain management and medication orders. |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 144
Deficiencies: 12
Date: Jan 3, 2017
Visit Reason
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.
Complaint Details
Complaint investigations #CT00020694, #21581, #21747, #21837 were conducted. Violations were substantiated and identified during the inspections.
Findings
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.
Deficiencies (12)
Failed to ensure a physician's order for a dental assessment was completed for Resident #52.
Failed to store medications at appropriate temperatures and ensure opened medications were dated and labeled.
Failed to transcribe a physician's telephone order or document medication administration per facility policy for Resident #25.
Failed to ensure care and services were provided during a medical emergency and failed to document appropriately.
Failed to ensure residents were free from verbal and physical abuse.
Failed to investigate and report allegations of neglect and/or abuse to the state agency.
Failed to ensure care and services were provided during dining and wound care.
Failed to assess urinary continence status and provide appropriate interventions.
Failed to provide adequate supervision to prevent wandering to a potentially dangerous environment.
Failed to ensure food preparation equipment was maintained in accordance with professional standards of food service safety.
Failed to maintain infection control standards during wound care.
Failed to ensure smoke barriers and self-closing doors met fire safety code requirements.
Report Facts
Licensed Bed Capacity: 144
Census: 137
Inspection Dates: January 3, 4, 5, 6, 2017; also October 30, 31, November 1, 2, 2017 for subsequent inspections.
Plan of Correction Review Date: 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| George Kingston | Administrator | Named as personnel contacted and responsible for plan of correction. |
| Shanta Griffiths | Director of Nursing Services (DNS) | Named as personnel contacted and responsible for plan of correction. |
| Kim Hriceniak | Supervising Nurse Consultant | Signed the violation letter dated January 11, 2017. |
| Anthony M. Bruno | Building Construction & Fire Safety Unit Supervisor | Signed fire safety related correspondence. |
| Connie Greene | Supervising Nurse Consultant | Signed response to state violation letter. |
| Nancy Downing | Nurse Consultant | Signed final page of report. |
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