Trinity Hospital Skilled Nursing Facility

In the surveyor’s words

From the most serious findings on record at Trinity Hospital Skilled Nursing Facility, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727Sep 5, 2025

  Based on interview and nursing schedule review, the facility failed to ensure that there was a Registered Nurse (RN) on duty 8 hours every day for 7 days a week. This failure had the potential to adversely affect resident's quality of care and quality of life with regards to overall health and well-being.Findings: A review of the Payroll Based Journal (PBJ, an electronic system for facilities to submit staffing information), for Fiscal Year Quarter 2 for 2025, (January 1-March 31), indicated the facility had no RN on duty for;01/04 Saturday (SA); 01/12 (Sunday SU);02/01 (SA); 02/08 (SA); 02/15 (SA); 02/22 (SA);03/01 (SA); 03/08 (SA); 03/22 (SA); and 03/29 (SA).A review of the PBJ for Fiscal Year Quarter 4 for 2024, (July1-September 30), indicated the facility had no RN on duty for;07/01… […]

• No harm, potential for more than minimal, widespreadF812Sep 5, 2025

  Based on observation, interview, and record review, the facility failed to maintain professional standards of practice to ensure food service safety for the residents of the facility when: 1. During the initial tour food preparation equipment was not sanitary. 2. Dietary staff failed to maintain clean, sanitary floors. 3. Dietary staff failed to keep foods stored away from unsanitary surfaces in the walk-in refrigerator. These failures had the potential for risk of cross contamination, to cause infection control issues, and lead to food borne illness for residents consuming food in the facility. […]

• No harm, potential for more than minimal, widespreadF727Jul 31, 2024

  Based on interview and nursing schedule review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours a day, seven days a week. This had the potential to adversely affect all of the residents' quality of life and quality of care. Findings: A review of the Payroll Based Journal (PBJ, an electronic system for facilities to submit staffing information) for Fiscal Year Quarter 1, 10/01/24-12/21/24, indicated the facility had no RN on duty for; 10/02/24, 10/03/24, 10/04/24, 10/6/24, 10/07/24, 10/08/24, 10/13/24, 10/14/24, 10/15/24, 10/20/24, 10/21/24, 10/22/24, 10/27/24, 10/28/24, 10/29/24, 11/03/24, 11/4/24, 11/05/24, 11/10/24, 11/11/24, 11/12/24, 11/17/24, 11/18/24, 11/19/24, 11/24/24, 11/25/24, 12/01/24, 12/02/24, 12/03/24, 12/09/24,12/10/24, 12/15/24, 12/16/24,… […]

• No harm, potential for more than minimal, widespreadF641Jul 21, 2023

  Based on interview and record review, the facility failed to ensure that Minimum Data Set (MDS, a standardized assessment tool that described resident health and functional status) assessments were completed accurately for eight out of nine sampled residents, (Residents 1, 2, 3, 4, 6, 7, 8 and 9) when the MDS's incorrectly indicated that these residents were using restraints (a device that limits a resident's movement). This failure had the potential for an inaccurate picture of the resident's status. […]

• No harm, potential for more than minimal, widespreadF711Jul 21, 2023

  Based on interview and record review, the facility failed to ensure that the attending Physician (AP), took an active role in the supervision of the care for 7 of 9 sampled residents (Resident 1, 3, 6, 7, 8, 9 and 10), when; 1. AP did not acknowledge, sign and date the current Active Orders (the physician's orders give the facility the legal authority to provide specific care and services to residents), for the months of June and July, 2023. 2. AP did not document a Progress Note (a note describing the Resident's current status at the time when the physician visited), in each Resident's medical record after he saw them each month. […]