Inspection Reports for Trinity Manor

This post-certification revisit was conducted to verify that previously cited deficiencies from an earlier survey were corrected.

All previously identified deficiencies listed on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.

This document is a Plan of Correction submitted by Trinity Manor in response to deficiencies cited during a regulatory inspection. It outlines corrective actions to address various issues identified in the facility's care and operations.

The plan addresses multiple deficiencies including notification of service discontinuation, medication and treatment order reviews, CPR certification coverage, resident care plan updates, audits of clinical and administrative processes, staff education, and environmental safety measures. The facility commits to ongoing monitoring and quality assurance activities to ensure compliance.

The inspection was an extended resurvey and investigation of complaint number KS00073740.

The facility had multiple deficiencies including failure to provide proper liability and appeal forms, failure to notify residents or responsible parties of changes, neglect in CPR provision for a full code resident resulting in death, inadequate abuse and neglect policies and reference checks, dignity and respect issues, failure to allow resident choice, inadequate social services, housekeeping and maintenance deficiencies, late MDS completion, incomplete care plans, failure to monitor dialysis and medication side effects, inadequate oral care, pressure ulcer care deficiencies, insufficient hydration, incomplete medication orders, failure to monitor psychotropic medication effects, expired medications not removed, unsanitary food preparation and serving, improper garbage disposal, lack of routine dental care, incomplete pharmacist follow-up, inadequate supervision to prevent falls, lack of transfer agreement with hospital, and failure to maintain nurse staffing records.

Complaint number KS00073740 triggered the extended resurvey and investigation.

This is a post-certification revisit to verify that previously cited deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.

The report documents that deficiencies previously cited under regulations 483.10(b)(11), 483.25(c), and 483.45(a) were corrected by 11/15/2013.

The inspection was conducted based on complaint investigations #69468 and #68102 regarding failure to notify physicians of changes and treatment delays, and pressure ulcer care.

The facility failed to notify resident #1's physician of a delay in initiation of ordered physical therapy, resulting in a stage 4 pressure ulcer. The facility also failed to provide timely treatment and services to prevent and heal pressure sores for residents #1 and #3, including failure to reposition resident #3 and use heel protectors as care planned. Additionally, there was a failure to provide specialized rehabilitative services (physical therapy) in a timely manner for resident #1.

The visit was triggered by complaint investigations #69468 and #68102 concerning failure to notify physicians of changes and delays in treatment, and inadequate pressure ulcer care.

This visit was a post-certification revisit to verify that previously reported deficiencies had been corrected.

The report shows that all previously cited deficiencies identified by regulation numbers 483.10(b)(5)-(10), 483.10(b)(1), 483.25(l), and 483.60(c) were corrected as of the revisit date.

This document is a Plan of Correction submitted by Trinity Manor in response to deficiencies cited in a prior inspection, addressing compliance with Federal Medicare and Medicaid requirements.

The plan outlines corrective actions including the use of Generic Notice CMS 10123 for therapy discontinuation notifications, revisions to resident care plans to include adverse reactions for medications with black box warnings, and pharmacist reviews of these revised care plans. Monitoring and reporting procedures are established to ensure ongoing compliance.

The licensure survey was conducted as part of the facility's renewal process.

The survey resulted in findings of no deficiency citations.

Health Resurvey #DA1Y11 conducted to assess compliance with regulatory requirements including medication monitoring and resident notification procedures.

The facility failed to use the required CMS 10123 form to notify residents of their rights to appeal the end of skilled services. The facility also failed to ensure residents' drug regimens were free from unnecessary drugs by not adequately monitoring medications with black box warnings (BBW). Consultant pharmacist failed to identify and report lack of monitoring of BBW medications in care plans for multiple residents.

This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.

The revisit confirmed that the deficiency related to regulation 483.10(b)(2) was corrected as of 05/10/2012. No other deficiencies were noted.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a complaint investigation (Trinity Manor Complaint 041212).

The plan of correction alleges substantial compliance with Federal Medicare and Medicaid requirements and outlines corrective actions related to resident rights and confidentiality, including staff in-service training and monitoring.

Related to Trinity Manor Complaint 041212; the plan addresses deficiencies cited in that complaint.

The inspection was conducted as a complaint investigation (#KS00056197) regarding the facility's failure to allow a resident to access and release their own medical records.

The facility failed to allow one of four sampled residents the right to obtain and release their own medical information to persons of their choosing. Interviews and record reviews confirmed that staff did not obtain the resident's permission before releasing medical information to the resident's case manager.

The complaint investigation #KS00056197 found that the facility did not allow resident #101 to obtain or release their medical information. Staff released information to the resident's case manager without the resident's permission, citing fluctuating confusion and reliance on a durable power of attorney instead of the resident's consent.

This document is a Plan of Correction submitted by Trinity Manor in response to deficiencies cited in a complaint investigation.

The plan addresses delays in therapy initiation, treatment and services to prevent pressure sores, and provision of specialized rehabilitation services, with corrective actions and monitoring plans outlined.

This plan of correction is related to a complaint investigation identified as Trinity Manor 102913 Complaint.