Inspection Reports for
Trinity Manor
510 W. FRONTVIEW STREET, DODGE CITY, KS, 67801-2213
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
13.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
128% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
87% occupied
Based on a January 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 40
Deficiencies: 3
Date: Jan 23, 2025
Visit Reason
The inspection was conducted to evaluate compliance with medication administration, food safety, and infection prevention standards at the nursing home.
Findings
The facility failed to ensure residents were free from medication errors by crushing delayed-release and extended-release medications. The kitchen failed to store, prepare, and serve food in a sanitary manner. The facility also failed to implement a water management program to prevent Legionella disease.
Deficiencies (3)
F 0760: The facility failed to ensure residents were free from significant medication errors by crushing delayed-release and extended-release medications prior to administration, placing residents at risk for adverse reactions.
F 0812: The facility failed to store, prepare, and serve food in a sanitary manner, including undated opened food containers, food stored on the floor, and unclean utensil drawers, risking resident safety.
F 0880: The facility failed to implement a water management program for Legionella disease, placing residents at risk of contracting infectious processes.
Report Facts
Residents present: 40
Sample size: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Administered crushed delayed-release and extended-release medications to residents R19 and R21 |
| Administrative Nurse D | Administrative Nurse | Verified extended-release medications should not be crushed and planned in-service for nursing staff |
| DS CC | Dietary Staff | Verified opened food bags should be dated and food boxes should not be stored on the floor |
| DS BB | Dietary Staff | Verified drawers needed cleaning and food boxes should not be stored on the floor |
| Administrative Staff A | Administrative Staff | Reported the facility lacked a waterborne pathogen/Legionella program |
Inspection Report
Routine
Census: 40
Deficiencies: 3
Date: Jan 23, 2025
Visit Reason
The inspection was conducted to assess compliance with medication administration, food safety, and infection prevention standards at the nursing home.
Findings
The facility failed to ensure residents were free from medication errors by crushing delayed-release and extended-release medications, failed to store and serve food in a sanitary manner, and failed to implement a water management program to prevent Legionella disease, placing residents at risk.
Deficiencies (3)
F0760: The facility failed to ensure residents R19 and R21 remained free from medication errors when staff crushed delayed-release and extended-release medications prior to administration, risking adverse reactions.
F0812: The facility failed to store, prepare, and serve food in a sanitary manner, including undated opened food containers, food stored on the floor, unclean utensil drawers, and cracked light covers in the kitchen.
F0880: The facility failed to implement a water management program for Legionella disease, placing residents at risk of contracting infectious processes.
Report Facts
Residents census: 40
Sample size: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Administered crushed delayed-release and extended-release medications to residents R19 and R21 |
| Administrative Nurse D | Administrative Nurse | Verified that extended-release medications should not be crushed and planned in-service for nursing staff |
| DS CC | Dietary Staff | Verified undated opened food and improper food storage in kitchen |
| DS BB | Dietary Staff | Verified unclean utensil drawers and food storage issues in kitchen |
| Administrative Staff A | Administrative Staff | Reported lack of waterborne pathogen/Legionella program |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Date: Jul 15, 2024
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where a cognitively impaired resident fell down basement stairs after a malfunctioning key-coded door was not reported as defective by housekeeping staff.
Complaint Details
The investigation was triggered by a complaint regarding a malfunctioning basement door that was not reported by housekeeping staff. The complaint was substantiated as the resident fell through the door and sustained serious injuries.
Findings
The facility failed to provide adequate supervision and ensure a safe environment free from accident hazards, resulting in a resident falling down seven basement stairs and sustaining major injuries including a head lump and three fractured ribs. The malfunctioning basement door was not reported timely, placing the resident in immediate jeopardy.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provide adequate supervision to prevent accidents, resulting in a resident falling down basement stairs due to a malfunctioning door not reported by staff. This caused immediate jeopardy with major injuries including a head lump and three fractured ribs.
Report Facts
Residents present: 41
Steps fallen: 7
Rib fractures: 3
Tylenol dosage: 650
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Licensed Nurse | Reported resident fall and provided care including medication and physician notification |
| Housekeeping Staff C | Failed to report malfunctioning basement door | |
| Administrative Staff A | Provided statements regarding door malfunction and incident | |
| Maintenance Staff H | Checked and changed door locking mechanism after incident | |
| Certified Nurse Aide D | Assisted resident post-fall and provided observations |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Date: Feb 8, 2024
Visit Reason
The inspection was conducted following a complaint investigation triggered by an incident where a resident fell out of a wheelchair during transport in the facility van and sustained a femur fracture.
Complaint Details
The complaint investigation was substantiated. Resident 1 fell out of the wheelchair during transport after staff swerved to avoid deer. Staff failed to call 911 immediately and transported the resident unsecured back to the facility. The resident required emergency medical transport and was diagnosed with a left distal femur fracture.
Findings
The facility failed to ensure a safe environment during resident transport when staff did not properly secure a resident with a lap belt, resulting in the resident falling and sustaining a left femur fracture. Staff also failed to immediately notify emergency services, transporting the resident unsecured back to the facility, placing the resident in immediate jeopardy.
Deficiencies (1)
F 0689: The facility failed to ensure the lap belt was snug on Resident 1 during transport, resulting in the resident falling out of the wheelchair and sustaining a left femur fracture. Staff failed to notify 911 immediately and transported the resident unsecured approximately 20 miles back to the facility.
Report Facts
Resident census: 41
Fall Risk Score: 16
Fall Risk Score: 19
Distance transported unsecured: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SSD C | Social Services Designee | Named in the finding for failing to secure the resident and failing to notify EMS immediately. |
| LN D | Licensed Nurse | Documented the incident and called 911 after being informed by SSD C. |
| Administrative Nurse B | Administrative Nurse | Informed LN D about resident's EMS transport and confirmed facility expectations. |
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 3
Date: Feb 9, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home operations, including resident care, medication management, and food safety.
Findings
The facility failed to notify the State Long-Term Care Ombudsman of resident hospitalizations, did not adequately monitor medication use for one resident, and failed to maintain sanitary food storage conditions, creating potential risks to residents.
Deficiencies (3)
F 0623: The facility failed to send timely notification of facility-initiated hospitalization transfer/discharge notices to the Office of the State Long-Term Care Ombudsman for residents R40 and R34.
F 0757: The facility failed to ensure adequate monitoring of medication for Resident R21 by not decreasing the dose of Zoloft as ordered and not having timely lab results for diabetes management.
F 0812: The facility failed to provide sanitary food storage, with unlabeled and undated opened food items in the refrigerator, risking foodborne illness to residents.
Report Facts
Residents present: 43
Residents sampled: 12
Residents reviewed for unnecessary medications: 5
Days delay in medication dose reduction: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Staff | Unaware of requirement to notify Ombudsman of hospitalizations | |
| Administrative Nurse D | Unaware of social service process for transfers/discharge and responsible for medication record reviews | |
| Administrative Staff A | Aware of notification requirement but confirmed no notices were sent | |
| Certified Medication Aide (CMA) R | Confirmed Resident R21 took Zoloft daily | |
| Dietary Staff CC | Reported food labeling practices during kitchen tour | |
| Dietary Staff BB | Stated staff should label food products with dates |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 7
Date: Jul 15, 2021
Visit Reason
The inspection was conducted based on complaints and concerns regarding failure to notify residents of Medicare coverage, misappropriation of resident funds, medication management issues, staffing qualifications, and food safety practices.
Complaint Details
The investigation was complaint-driven, focusing on issues including failure to notify residents of Medicare coverage changes, misappropriation of resident funds, medication management failures, staffing qualifications, and food safety violations. The complaints were substantiated with findings of minimal harm.
Findings
The facility failed to notify a resident of Medicare non-coverage timely, misappropriated a resident's stimulus check without consent, did not follow consultant pharmacist recommendations for medication adjustments, failed to adequately follow diabetic orders and document properly, did not ensure gradual dose reductions for psychotropic medications, failed to employ a Certified Dietary Manager, and failed to store food safely and use gloves properly in the kitchen.
Deficiencies (7)
F 0582: The facility failed to notify Resident R183 in advance of Medicare Part A services ending and did not provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN).
F 0602: The facility misappropriated Resident R133's government stimulus check to pay facility charges without the resident's consent.
F 0756: The facility failed to follow up on consultant pharmacist recommendations for medication dose reductions for Resident R2.
F 0757: The facility failed to adequately follow physicians' diabetic orders and document appropriately for Resident R2, including failure to administer insulin as ordered.
F 0758: The facility failed to ensure gradual dose reductions were attempted for psychotropic medications for Resident R2 as required.
F 0801: The facility failed to employ a Certified Dietary Manager as required.
F 0812: The facility failed to store foods safely and sanitary by not dating and resealing opened food items, failing to discard expired food, and improper glove use by dietary staff.
Report Facts
Residents in census: 32
Residents reviewed for beneficiary notices: 3
Residents sampled for property misappropriation: 12
Stimulus check amount: 1200
Residents sampled for medication review: 12
Residents reviewed for unnecessary medications: 5
BG readings greater than 300 mg/dl not treated: 24
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 12, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from an earlier survey were corrected.
Findings
All deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 30
Inspection Report
Plan of Correction
Deficiencies: 31
Date: Apr 23, 2014
Visit Reason
This document is a Plan of Correction submitted by Trinity Manor in response to deficiencies identified during a regulatory inspection. It outlines corrective actions to address various compliance issues.
Findings
The plan details corrective actions for multiple deficiencies including notification of service discontinuation, medication and treatment communication, CPR certification, dental care, resident preferences, fall prevention, hydration, medication management, dietary services, and environmental safety. The facility commits to audits, staff education, and ongoing monitoring to ensure compliance.
Deficiencies (31)
F156-D: The facility started using Generic Notice CMS 10123 for notification of intent to stop skilled services and assigned responsibility for timely notice delivery and auditing.
F157-D: Family and residents were notified of medication and treatment changes; staff educated on notification policies; audits and ongoing education planned.
F224-J: CPR certification ensured for staff on all shifts; code status binders updated and audited regularly; staff educated on protocols for unobtainable vitals.
F226-E: Staff responsible for hiring trained on proper procedures including reference and background checks; audits conducted and reported.
F241-E: Staff educated to avoid use of disrespectful nicknames or terms of endearment; supervisors monitor and report ongoing use.
F242-D: Resident preferences for awakening time assessed and documented; staff training and audits implemented to ensure adherence.
F250-D: Dental care concerns addressed through resident appointments, care plan updates, audits, and coordination with hospice staff.
F253-E: Housekeeping and maintenance services improved; unsafe practices documented and corrected weekly; reports made to QA.
F273-D: MDS Coordinator trained; admission MDS audits conducted to ensure timely completion; results reported monthly.
F279-E: Care plans updated for fluid restriction, dental care, nail care, and pressure ulcer prevention; audits and education ongoing.
F280-E: Falls reviewed by interdisciplinary team; audits and daily meetings implemented to prevent falls; care plans updated accordingly.
F309-D: Fluid restriction orders communicated; audits on dialysis and skin assessments conducted; staff education provided.
F311-D: Oral care equipment provided; audits and education on oral care included in ADL care plans; ongoing monitoring planned.
F312-D: Nail care included in care plans; audits on cognitively impaired residents; staff education provided; monitoring ongoing.
F314-G: Diet fortified and treatments ordered; audits on pressure sore interventions and fortified diets; staff education provided.
F315-D: Care plans reviewed with staff; bladder diaries initiated; education on incontinence care provided; audits conducted.
F323-E: Resident environment maintained free of hazards; falls prevention interventions audited and reviewed; maintenance walk-throughs weekly.
F327-D: Residents provided sufficient fluids; staff educated on hydration; audits conducted weekly for 2 months.
F329-D: Physician orders clarified; audits on medication orders and behavior tracking sheets; staff education on protocols provided.
F356-C: Daily nurse staffing data posted publicly; audits conducted weekly; findings reported monthly to QA.
F364-D: Food prepared to conserve nutritive value and appearance; staff trained on puree diets; dietician monitors meal preparation.
F371-F: Food stored, prepared, and served under sanitary conditions; staff trained on hairnet use, tray card handling, and cleaning schedules.
F372-F: Dumpsters replaced with lids; maintenance walk-throughs conducted weekly; findings reported to QA monthly.
F411-D: Resident with broken teeth identified; dental issues discussed; audits on dental care conducted quarterly.
F428-D: Medication orders audited for frequencies; behavior and side effect tracking sheets initiated; staff educated on protocols.
F431-E: Expired medications destroyed; staff educated on expired medication removal; audits on drug storage conducted weekly.
F497-F: CNAs required to complete 12 hours of in-services annually; audits on in-service completion conducted quarterly.
F509-C: Diagnostic services agreement in place and reviewed yearly to ensure compliance.
F519-C: Written transfer agreement with hospitals in effect and reviewed yearly to ensure timely resident transfers.
F520-F: Quality assessment and assurance committee established; meetings held to monitor plan of correction progress.
S0600-F: Dietary concerns managed by qualified dietary manager; facility seeking certified dietary manager; QA committee oversight.
Report Facts
Residents: 57
In-service hours: 12
In-services per quarter: 3
Audit frequency: 2
Audit frequency: 3
Audit frequency: 4
Audit frequency: 30
Audit frequency: 14
Audit frequency: 5
Audit frequency: 2
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 28
Date: Apr 9, 2014
Visit Reason
Extended resurvey and investigation of complaint number KS00073740 at Trinity Manor nursing facility.
Complaint Details
This inspection was conducted as an extended resurvey and investigation of complaint number KS00073740.
Findings
The facility was found deficient in multiple areas including failure to provide proper notice of rights, failure to notify residents or families of changes in condition, neglect in CPR initiation for a full code resident, inadequate abuse and neglect policies, dignity and respect issues, failure to honor resident choices, insufficient social services, housekeeping and maintenance deficiencies, late MDS assessments, incomplete and untimely care plans, dialysis communication issues, dental care deficiencies, pressure ulcer prevention and treatment failures, inadequate hydration, incomplete medication orders, lack of monitoring for psychotropic medication side effects, expired medication management failures, insufficient nurse aide inservice training, lack of diagnostic service agreements, absence of hospital transfer agreements, and ineffective quality assurance committee oversight.
Deficiencies (28)
F156: Facility failed to provide proper liability and appeal forms informing residents of their rights regarding Medicare Part A service termination.
F157: Facility failed to notify residents or responsible parties of changes in condition or treatment for 2 residents.
F224: Facility neglected to initiate CPR on a full code resident found non-responsive, placing resident in immediate jeopardy; resident expired.
F226: Facility failed to implement abuse, neglect, and exploitation policies including immediate reporting and reference checks for employees.
F241: Facility failed to maintain resident dignity by staff using inappropriate nicknames and labels during care.
F242: Facility failed to allow a resident to choose preferred time of awakening.
F250: Facility failed to provide medically related social services for hospice and dental care needs for 2 residents.
F253: Facility failed to maintain sanitary, orderly, and comfortable environment; multiple maintenance and housekeeping deficiencies observed.
F273: Facility failed to complete admission MDS in a timely manner for 1 resident.
F279: Facility failed to develop individualized, comprehensive care plans addressing dialysis communication, dental care, oral hygiene, pressure ulcer prevention, and ADL needs for multiple residents.
F280: Facility failed to review and revise care plans timely for multiple residents related to falls, toileting, strength, and dental care.
F309: Facility nursing staff lacked knowledge of current dialysis orders and failed to communicate timely with dialysis center; failed to document and notify physician of bruises for a resident on Warfarin.
F311: Facility failed to provide appropriate dental hygiene equipment and consistent assistance to maintain/improve oral care for a resident.
F312: Facility failed to provide necessary nail care services to a cognitively impaired resident.
F314: Facility failed to provide treatment and services to prevent and heal pressure ulcers for 2 residents, including repositioning, nutrition, and barrier cream application.
F315: Facility failed to follow individualized care plans for toileting and incontinence for 2 residents.
F323: Facility failed to maintain a safe environment free of accident hazards including unsecured chemicals, delayed exit door alarms, broken glass, and inadequate supervision to prevent falls for a cognitively impaired resident.
F327: Facility failed to provide sufficient fluid intake to maintain hydration for a resident with history of urinary tract infections.
F329: Facility failed to ensure complete medication orders, monitor psychotropic medication side effects, and notify physician of blood sugars outside ordered parameters for multiple residents.
F431: Facility failed to remove expired medications from medication rooms and carts, and failed to maintain sanitary medication storage areas.
F497: Facility failed to ensure all nursing staff completed required annual inservice education hours.
F509: Facility failed to have an agreement with an approved provider for diagnostic services.
F519: Facility failed to have a transfer agreement with a local hospital.
F520: Facility failed to maintain an effective quality assurance committee to address multiple quality of care and quality of life deficiencies.
F364: Facility failed to provide pureed diet with proper nutritional value and consistent preparation methods.
F371: Facility failed to prepare and serve food under sanitary conditions including staff not wearing hairnets, improper ice machine drainage, unsanitary food handling, and improper food storage.
F372: Facility failed to properly dispose of garbage and refuse; dumpsters were overflowing and lids were open.
F411: Facility failed to provide routine dental services for a resident with broken and carious teeth, including failure to arrange dental appointments and document resident wishes.
Report Facts
Resident census: 56
Deficiency counts: 32
Falls count: 13
Inservice completion rate: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nursing Staff | Verified multiple findings including failure to initiate CPR, failure to notify families, and failure to maintain quality assurance. |
| Licensed Nursing Staff K | Licensed Nurse | Nurse on duty during resident death who failed to initiate CPR. |
| Direct Care Staff QQ | Direct Care Staff | Reported on resident care refusals and pressure ulcer care. |
| Dietary Staff BB | Dietary Staff | Prepared pureed foods without measuring ingredients. |
| Consultant Pharmacist DDD | Pharmacist Consultant | Acknowledged failure to follow up on medication orders and monitoring. |
| Administrative Staff B | Administrative Staff | Responsible for staff inservice education monitoring. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Dec 17, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated in the plan of correction.
Findings
The report confirms that deficiencies previously reported under regulations 483.10(b)(11), 483.25(c), and 483.45(a) were corrected by 11/15/2013.
Deficiencies (3)
Regulation 483.10(b)(11): Previously cited deficiency was corrected by 11/15/2013.
Regulation 483.25(c): Previously cited deficiency was corrected by 11/15/2013.
Regulation 483.45(a): Previously cited deficiency was corrected by 11/15/2013.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 3
Date: Oct 29, 2013
Visit Reason
The inspection was conducted based on complaint investigations #69468 and #68102 regarding resident care and treatment issues.
Complaint Details
The inspection was triggered by complaint investigations #69468 and #68102 concerning failure to notify physicians of changes, treatment of pressure ulcers, and timely provision of physical therapy.
Findings
The facility failed to notify a resident'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 pressure ulcers for two residents, including failure to reposition and use heel protectors. Additionally, there was a delay in obtaining specialized rehabilitative services (physical therapy) for one resident.
Deficiencies (3)
F 157: The facility failed to notify resident #1's physician of a delay in initiation of ordered physical therapy which included assessment of a surgical wound.
F 314: The facility failed to ensure 2 of 3 residents received necessary treatment and services to prevent and heal pressure ulcers, including timely initiation of physical therapy and repositioning with heel protectors.
F 406: The facility failed to provide specialized rehabilitative services (physical therapy) in a timely manner for resident #1, resulting in a 10 day delay in initiation of therapy.
Report Facts
Resident census: 44
Delay in physical therapy initiation: 10
Pressure ulcer size: 2.5
Pressure ulcer size: 3
Physical therapy frequency: 2
Physical therapy frequency: 3
Duration of physical therapy order: 6
Duration resident #3 remained in wheelchair without repositioning: 204
Pressure ulcer size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician E | Primary Care Physician | Notified of resident #1's pressure ulcer and assessed wound |
| Physician Assistant F | Ordered physical therapy and assessed resident #1's surgical wound | |
| Administrative Nurse B | Administrative Nurse | Verified delay in physical therapy initiation and failure to notify physicians |
| Licensed Nurse I | Verified receipt of physical therapy orders and pressure ulcer discovery |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 30, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously reported deficiencies identified by regulation numbers 483.10(b)(5)-(10), 483.10(b)(1), 483.25(l), and 483.60(c) were corrected by the revisit date of 04/30/2013.
Deficiencies (3)
Regulation 483.10(b)(5)-(10), 483.10(b)(1): Previously cited deficiencies were corrected by 04/30/2013.
Regulation 483.25(l): Previously cited deficiency was corrected by 04/30/2013.
Regulation 483.60(c): Previously cited deficiency was corrected by 04/30/2013.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Apr 15, 2013
Visit Reason
This document is a Plan of Correction submitted by Trinity Manor in response to deficiencies identified in a prior inspection, addressing compliance with federal Medicare and Medicaid requirements.
Findings
The plan outlines corrective actions including the use of Generic Notice CMS 10123 for therapy discontinuation, revisions to resident care plans to include adverse reactions for medications with black box warnings, and pharmacist review of these care plans. Nursing administration will monitor compliance and report findings to the Quality Assurance/Quality Improvement Committee.
Deficiencies (3)
F156-D: The facility started using Generic Notice CMS 10123 to notify residents prior to stopping skilled therapies. Notices will be reviewed monthly and reported to the Quality Assurance/Quality Improvement meeting.
F329-E: Care plans for multiple residents will be revised to include adverse reactions for medications with black box warnings. Nursing staff will receive in-service training on these revisions and documentation requirements.
F428-E: Revised care plans with black box warnings will be reviewed by the consulting pharmacist to ensure adverse reactions are appropriately included. Compliance will be reported monthly.
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 10, 2013
Visit Reason
The licensure survey was conducted as part of the facility's renewal process to assess compliance with regulatory requirements.
Findings
The survey resulted in findings of no deficiency citations, indicating full compliance with licensure standards.
Inspection Report
Re-Inspection
Census: 44
Deficiencies: 3
Date: Apr 10, 2013
Visit Reason
Health resurvey to assess compliance with prior deficiencies and medication monitoring requirements.
Findings
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 reviews did not identify or address the lack of monitoring of BBW medications in care plans for multiple residents.
Deficiencies (3)
F156: The facility failed to use the required CMS 10123 Generic Notice to notify residents of their rights to appeal the plan to stop skilled therapies.
F329: The facility failed to monitor residents for adverse side effects associated with medications having black box warnings, and care plans lacked specific adverse reaction information for these medications.
F428: The pharmacist failed to report irregularities related to lack of monitoring of medications with black box warnings in care plans, and these reports were not acted upon.
Report Facts
Residents sampled for unnecessary drug review: 10
Residents with medication monitoring failures: 9
Facility census: 44
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 10, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection of Trinity Manor ALF.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a record of the Plan of Correction submission.
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 10, 2012
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as of the revisit date.
Findings
The report confirms that the deficiency identified under regulation 483.10(b)(2) was corrected by the revisit date of 2012-05-10. No other deficiencies are listed.
Deficiencies (1)
Regulation 483.10(b)(2) deficiency was corrected as of 2012-05-10.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Apr 18, 2012
Visit Reason
This document is a plan of correction submitted by the facility in response to deficiencies cited in a complaint investigation.
Findings
The plan of correction addresses issues related to resident rights, specifically the right to access clinical records within 24 hours and to obtain photocopies at a reasonable cost. Staff were assigned in-service training on resident rights to prevent recurrence.
Deficiencies (2)
F0000 This plan of correction constitutes a written allegation of substantial compliance with Federal Medicare and Medicaid requirements. The facility will provide a complete copy of the deficiency list to the Quality Assurance Committee for review and appropriate actions.
F153-D The facility will ensure residents or their legal representatives have the right to access all records within 24 hours and to purchase photocopies at community standard cost with 2 working days advance notice. Staff received in-service training on resident rights and confidentiality to prevent recurrence.
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Apr 12, 2012
Visit Reason
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.
Complaint Details
The complaint investigation #KS00056197 found that the facility did not allow resident #101 to obtain or release their own medical information. Staff did not ask the resident for permission to release information and instead relied on the durable power of attorney. The resident was observed to be disoriented and confused during the investigation.
Findings
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. Staff released information only after checking for a durable power of attorney and did not obtain permission from the resident.
Deficiencies (1)
483.10(b)(2) The facility failed to allow resident #101 the right to access and purchase copies of their own medical records and to release their medical information to persons of their choosing.
Report Facts
Resident census: 49
Residents sampled: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse A | Reported that resident #101's case manager requested medical information without resident permission | |
| Social Service Staff C | Confirmed refusal to release information without resident permission due to fluctuating confusion | |
| Administrative Nurse B | Reported staff checked for durable power of attorney before releasing information and did not ask resident for permission |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N029001 POC
Visit Reason
This document is a Plan of Correction related to a facility identified by State ID N029001, intended to address deficiencies noted in a prior inspection.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a placeholder or notification for the Plan of Correction process.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: N029001 POC K8WF11
Visit Reason
This document is a Plan of Correction submitted by Trinity Manor in response to deficiencies cited in a complaint investigation.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Trinity Manor 102913 Complaint.
Findings
The plan addresses delays in therapy initiation, treatment and services to prevent pressure sores, and provision of specialized rehabilitation services. Corrective actions include audits, education, monitoring, and weekly interdisciplinary meetings to ensure compliance.
Deficiencies (3)
F157: Resident #1 was notified of delay in therapy initiation on 10/1/2013. Facility will audit therapy orders weekly and notify physicians if therapy is not started within 48 hours.
F314: Resident #1's left elbow surgical site is dressed and monitored per physician orders. Residents at risk of skin breakdown will receive necessary treatment and skin checks will be conducted regularly.
F406: Facility will notify physicians of therapy delays over 48 hours. Weekly meetings will review therapy progress and compliance will be monitored monthly.
Report Facts
Complete Date: Nov 19, 2013
Complete Date: Oct 28, 2013
Complete Date: Nov 15, 2013
Complete Date: Nov 6, 2013
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N029001 POC X5SZ11
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified by Event ID X5SZ11 for the facility with State ID N029001.
Findings
No deficiency details or findings are included in this Plan of Correction document. It only references the related deficiency report but states no records found.
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