Trinity Trace Community Care Center

In the surveyor’s words

From the most serious findings on record at Trinity Trace Community Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF678Sep 23, 2022

  46981 Based on record reviews and interviews, the facility failed to have effective system in place to ensure residents' advanced directives were correctly initiated for 1 resident (#106), and ensure residents' medical records reflected the residents' wishes for emergency basic life support for 3 (#7, #103, and #106) of 32 (#7, #10, #11, #23, #36, #42, #43, #49, #51, #54, #58, #62, #65, #71, #79, #82, #84, #91, #92, #101, #103, #104, #106, #107, #306, #405, #406, #407, #408, #409, #410, and #411) sampled residents reviewed for Advance Directives. The deficient practice resulted in an Immediate Jeopardy situation on [DATE] for Resident #106 when she was found unresponsive, and CPR was not initiated by S5LPN as requested in Resident #106's Advanced Directive. […]

• Immediate jeopardy, patternF835Sep 23, 2022

  46308 46981 Based on record reviews and interviews, the facility failed to be administered in a manner which enabled it to use its resources effectively and efficiently to ensure an effective system was in place to ensure advance directives were followed for 3 (#7, #103, and #106) of 32 (#7, #10, #11, #23, #36, #42, #43, #49, #51, #54, #58, #62, #65, #71, #79, #82, #84, #91, #92, #101, #103, #104, #106, #107, #306, #405, #406, #407, #408, #409, #410, and #411) sampled residents reviewed for Advanced Directives. The deficient practice resulted in an Immediate Jeopardy situation on [DATE] for Resident #106 when she was found unresponsive, and CPR was not initiated by S5LPN as requested in Resident #106's Advanced Directive. […]

• No harm, potential for more than minimal, patternF880Apr 15, 2025

  Based on observations, interviews, and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff: 1. Properly utilized Enhanced Barrier Precaution (EBP) Personal Protective Equipment (PPE) during incontinence care for 2 (#2 and #R1) of 3 (#2, #3 and #R1) residents whom required EBP; and 2. […]

• No harm, potential for more than minimal, patternF641Sep 25, 2024

  Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 2 (#1 and #107) residents out of a total of 25 sampled residents by failing to ensure: 1. Resident #1 was coded correctly for the use of an antidiuretic; and 2. Resident #107 was coded correctly for discharge. Findings: 1. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #1's Quarterly MDS with an ARD of 07/23/2024 revealed Section N:G: Diuretic: No. Review of Resident #1's Physician Orders revealed the following: Start date: 05/21/2024, End Date: 09/08/2024: Furosemide 20 mg Give 20 mg by mouth two times a day. On 09/24/2024 at 9:48 p.m., an interview was conducted with S4CCC. […]

• No harm, potential for more than minimal, patternF755Sep 25, 2024

  Based on record review, observations, and interviews, the facility failed to provide pharmaceutical services, including procedures that assure the dispensing and administering of all drugs and biologicals, to meet the needs of each resident. The facility failed to ensure insulin pens were primed prior to administration of insulin per manufacturer's guidelines for 3 of 3 (#11, #30, and #76) residents observed for insulin administration. Findings: Review of the facility's policy titled Insulin/Insulin Flexpens and Insulin Documentation dated 01/29/2013, revealed the following, in part: FlexPen Insulin Administration 7. […]