Inspection Reports for Trinity Oaks II
117 SHADY REST ROAD,, ELLWOOD CITY, PA, 16117
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
70% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
73% occupied
Based on a July 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 22
Capacity: 30
Deficiencies: 9
Date: Jul 24, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted to review compliance with licensing requirements.
Findings
The facility had multiple deficiencies including unqualified direct care staff, missing handrails, improper refrigerator temperatures, combustible materials accessible to residents, missed fire drills, medication labeling errors, improper medication storage and record keeping, and incomplete resident assessments. All deficiencies had plans of correction accepted and were implemented by November 8, 2024.
Deficiencies (9)
Staff person A does not have a high school diploma, GED diploma, or active registry status on the Pennsylvania nurse aide registry and provides unsupervised direct care to residents.
No handrail at the outdoor step at the laundry room or at the outdoor step by bedroom #7.
Refrigerator temperatures exceeded required limits: kitchen reach-in refrigerator was 52°F and pantry refrigerator was 42°F.
A can of flammable hairspray was left unattended and unlocked on the counter in the beauty shop.
The home did not conduct a fire drill in June 2024.
Medication labels for residents #1 and #2 did not match prescribed dosages, with resident #1's label allowing more frequent dosing and resident #2's label indicating twice daily instead of once daily.
Resident #3's blood glucose readings were recorded incorrectly on medication administration records.
Resident #3's medication administration record did not indicate the maximum daily dosage as prescribed.
Resident #2's initial assessment was not completed within 15 days of admission, and resident #4's support plan lacked documentation on bedside mobility device use and associated risks.
Report Facts
License Capacity: 30
Residents Served: 22
Total Daily Staff: 28
Waking Staff: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| George Knox | Administrator | Named in multiple deficiency findings and plans of correction |
Inspection Report
Renewal
Census: 18
Capacity: 30
Deficiencies: 10
Date: Aug 14, 2023
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 08/14/2023 to review compliance with licensing requirements.
Findings
The facility was found to have multiple deficiencies including incomplete criminal background checks, incomplete direct care training, inaccurate fire drill records, medication storage and labeling errors, incomplete medication administration records, incomplete resident assessments, and missing resident photos. Plans of correction were accepted and fully implemented by 10/03/2023.
Deficiencies (10)
Criminal history background check was not completed timely for a staff person.
Direct care staff person provided unsupervised ADL services without completing required training and competency test.
Fire drill records inaccurately reported staff participation; administrator counted self in drill logs.
Nighttime fire drills were held at the same time, not on different days or times as required.
Medication storage error: eye drops lacked an open date label.
Medication labeling errors: resident medications had incorrect instructions on pharmacy labels.
Medication administration record did not include all medications administered to resident #2.
Medication administration training record for staff person B was incomplete and missing documentation.
Resident assessments were not completed timely for residents #2 and #3.
Resident records lacked current photos for residents #1 and #3.
Report Facts
Total Daily Staff: 20
Waking Staff: 15
License Capacity: 30
Residents Served: 18
Deficiencies cited: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| George Knox | Named in relation to medication administration training deficiency and plan of correction. |
Inspection Report
Renewal
Census: 16
Capacity: 30
Deficiencies: 3
Date: Aug 16, 2022
Visit Reason
The inspection was an unannounced full renewal inspection conducted to review compliance with licensing requirements.
Findings
The inspection identified deficiencies related to expired first aid/CPR certifications among staff, holes in the shower room ceiling, and hot water temperatures exceeding the allowed maximum in two sinks. Plans of correction were submitted and implemented to address these issues.
Deficiencies (3)
No staff persons present who were currently certified in first aid, obstructed airway techniques and CPR on multiple dates.
Multiple holes in the ceiling near light fixtures in the main shower room.
Hot water temperature at two sinks exceeded 120°F, measuring up to 128.8°F.
Report Facts
Residents present: 16
License capacity: 30
Hot water temperature: 125.2
Hot water temperature: 119.6
Hot water temperature: 128.8
Hot water temperature: 127
Employees mentioned
| Name | Title | Context |
|---|---|---|
| George Knox | Administrator | Named as Administrator and involved in staff training and corrective actions. |
Notice
Capacity: 30
Deficiencies: 0
Date: Sep 7, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Trinity Oaks II Personal Care Home. It informs the facility that an annual inspection will be conducted within the next twelve months as required by state regulations.
Findings
The Department has approved the renewal application and issued a regular license. The document does not report any inspection findings but advises that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Maximum capacity: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 16
Capacity: 30
Deficiencies: 9
Date: Aug 19, 2021
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements at Trinity Oaks II.
Findings
The inspection identified several deficiencies including improper placement of carbon monoxide detectors, outdated boiler inspection certificates, uncovered trash receptacles, excessive hot water temperatures, lack of operable bedside lamps for residents, missing refrigerator/freezer thermometers, incomplete medical evaluations, medication labeling discrepancies, and unsecured poisonous materials. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (9)
Carbon monoxide detectors were placed less than 15 feet from fossil fuel burning devices and boiler inspection certificates were out of date.
Uncovered garbage can of food waste in the kitchen.
Hot water temperatures exceeded 120°F in kitchen and resident bathroom.
No operable lamp or source of lighting at bedside in resident room #13.
No thermometer present in refrigerator or freezer next to kitchen sink.
Resident #2's initial medical evaluation did not include pulse rate or allergies.
Resident #3's most recent medical evaluation did not include height.
Pharmacy labels on medications did not match MAR sheets for two residents.
Multiple containers of paint with poison labels were unlocked and accessible to residents.
Report Facts
License Capacity: 30
Residents Served: 16
Current Hospice Residents: 2
Waking Staff: 14
Total Daily Staff: 19
Water Temperature: 139.5
Water Temperature: 140.3
Water Temperature: 127.5
Water Temperature: 129.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| George Knox | Named in relation to hot water temperature deficiency plan of correction. |
Inspection Report
Complaint Investigation
Census: 16
Capacity: 30
Deficiencies: 1
Date: Jun 22, 2021
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 06/22/2021.
Complaint Details
The inspection was complaint-related and the submitted plan of correction was determined to be fully implemented.
Findings
The facility was found to have a deficiency where Resident #1's assessment was not updated to include home health services received 2-3 times per week from 11/6/20 to 6/18/21. The plan of correction was fully implemented and compliance was maintained.
Deficiencies (1)
Resident #1’s assessment dated 3/12/21 was not updated to include home health services 2-3 times per week from 11/6/20 to 6/18/21.
Report Facts
License Capacity: 30
Residents Served: 16
Staffing Hours: 18
Waking Staff: 14
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