Inspection Reports for Trinity Manor

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.

Complaint number KS00073740 triggered the extended resurvey and investigation.

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.

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 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.

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 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.

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 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.

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.

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

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.

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.

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.

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

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.