Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Trinity Hill Care Center during CMS and state inspections, most recent first.
A resident with a history of aggressive behavior and moderate cognitive impairment was involved in multiple physical altercations with other residents, including an incident where another resident with severe cognitive impairment was struck in the face, resulting in a laceration and a subdural hematoma requiring hospitalization and surgery. Despite documented behavioral risks and prior incidents, the facility did not provide adequate supervision or effective interventions to prevent the altercation, and did not substantiate the event as abuse according to its own policy.
A resident with atrial fibrillation, severe cognitive impairment, and a pacemaker was admitted while receiving Eliquis and Plavix, but the facility failed to develop a care plan addressing the risk of bleeding associated with these anticoagulants, as required by policy. Staff acknowledged the omission, attributing it to a change in the electronic medical record system and oversight.
A resident with a history of aggressive behaviors and moderate cognitive impairment was not adequately supervised, leading to a physical altercation with another resident who had severe cognitive impairment and was on anticoagulant therapy. The incident, which was unwitnessed by staff, resulted in a serious head injury and hospitalization for the injured resident. The aggressive resident's monitoring had been discontinued prior to the event, despite a documented pattern of similar incidents.
Two residents with psychiatric and cognitive conditions did not have their physician orders reviewed or renewed within the required 60-day timeframe, with a lapse of 127 days between signatures. Facility leadership and the Medical Director confirmed the orders were not signed as scheduled, and no policy on medical visits was provided for review.
A resident with severe cognitive impairment and mobility dependence was physically abused by another resident with a history of aggression and psychiatric diagnoses. The aggressor, who had previously refused medications and had prior altercations, slapped the victim in the hallway, resulting in facial redness. The incident was witnessed by staff and a non-staff member, and the facility failed to prevent the abuse as required by policy.
The facility failed to document and address grievances from the resident council regarding staff not folding clothing, cellphone usage during care, and residents' choice of bedtime. Despite a resolution to educate staff, the issue of cellphone usage persisted, indicating inadequate follow-through. Interviews revealed a lack of communication and awareness among staff responsible for addressing these concerns.
The facility failed to protect residents from abuse, as evidenced by multiple incidents of resident-to-resident altercations. One resident with dementia and schizophrenia was injured when another resident threw a chair, while another resident with vascular dementia was hit in the face. A third incident involved a resident being physically assaulted by another, resulting in pain and scratches. Despite policies prohibiting abuse, these events highlight the facility's failure to maintain a safe environment.
The facility failed to update care plans for residents involved in altercations, including a resident with dementia who was injured by another resident, and another resident with a history of altercations. Additionally, a newly admitted resident did not have an interdisciplinary care plan meeting. Interviews revealed a lack of clarity in responsibilities for updating care plans.
A facility failed to ensure pharmacy recommendations were reviewed by the provider and documented in a resident's clinical chart. The resident, with a history of traumatic brain injury and anxiety disorder, had missing pharmacy reviews and lab results in their chart. The facility lacked a clear policy for processing pharmacy recommendations, leading to unsigned recommendations and unaddressed lab tests. Interviews revealed the facility was revising its process for handling these recommendations.
A resident with multiple fractures and total dependence for oral hygiene did not receive necessary dental services despite complaints of pain and physician orders for evaluation. The process for scheduling dental appointments was not followed, resulting in the resident not being seen by a dentist or hygienist. This highlights a deficiency in the facility's management of physician orders.
The facility did not conduct the required annual water management plan meeting, as revealed by a review of the Water Management Plan and safety committee meeting minutes. The Director of Maintenance admitted to losing track of time, resulting in the meeting not being held. The administration confirmed the oversight, and the facility's policy requiring annual updates to environmental assessments was not followed.
A resident with diagnoses including osteomyelitis and major depressive disorder elected a DNR status, which was documented in the Advance Directives/Code Status Consent form. However, the physician's order incorrectly indicated a full code status. The error was identified by an LPN, and APRN acknowledged the mistake, noting that the order should have reflected the resident's DNR status.
A facility failed to obtain necessary consents from a resident's conservator upon admission. The resident, with psychiatric and neurological diagnoses, was admitted without completing required forms or contacting the conservator. Staff interviews revealed a lack of adherence to the facility's admission policy, which mandates obtaining conservator signatures for admission paperwork.
A resident admitted with a PICC line did not have their admission orders verified, leading to improper documentation and care. The facility failed to follow its policy on physician orders transcription and central line catheter protocol, resulting in unverified medication administration and inadequate catheter care. Staff interviews revealed poor communication and responsibility for verifying orders.
A resident with chronic health issues was observed using oxygen therapy without a physician's order documented in their medical records. The resident's care plan included oxygen use, but the quarterly assessment did not reflect this. An LPN confirmed the need for an order, but it was missing from the MAR and TAR, contrary to facility policy.
A resident with severe pain from a gunshot wound did not receive timely pain medication due to a nurse's inaction. Despite multiple requests and notifications from a nursing assistant, the nurse did not administer the medication, resulting in the resident experiencing prolonged pain and a fall. Facility policies on medication administration and pain management were not followed.
A resident with anxiety disorder was unable to access Lorazepam PRN due to the facility's failure to ensure emergency medication availability and proper controlled substance management. The resident became agitated and injured themselves. The facility's system for managing controlled substances was inadequate, with unsecured records and improper audit procedures.
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in documentation and accessibility. A resident with alcohol-induced dementia did not have complete documentation of required checks. Another resident's admission paperwork was incomplete, lacking conservator consent. Additionally, pharmacy recommendations and lab results were missing from a third resident's chart, indicating lapses in record-keeping and adherence to facility policies.
The facility failed to label and date food items appropriately, as observed during a kitchen tour. Five brown bags in the refrigerator lacked identifiable information, and four large bins contained undated or expired food items. The Food Service Director confirmed that these items should have been labeled and dated according to facility policy.
The facility failed to maintain a complete and accurate medical record for a resident with a substance abuse disorder. The resident's refusals to attend the Recovery Program groups were not documented, despite directives in the Resident Care Plan and confirmation from the Director of Social Work, the Director of Nursing, and the Clinical Director.
Failure to Prevent Resident-to-Resident Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect residents from abuse and did not provide adequate supervision to prevent a resident-to-resident altercation resulting in injury. One resident with a history of aggressive behaviors and moderate cognitive impairment had multiple prior incidents of physical altercations with other residents, including hitting and slapping, which were documented in the clinical record. The care plan for this resident included interventions such as every 15-minute checks, psychiatric and social services follow-up, and specific behavioral interventions, but these measures did not prevent further incidents. On a specific occasion, a resident with severe cognitive impairment and dependent on staff for bathroom use was struck in the face by the resident with a history of aggression. The incident was unwitnessed by staff, and the injured resident sustained a significant laceration to the temporal area, which resulted in active bleeding. The injured resident was subsequently diagnosed with a hyperacute subdural hematoma and required hospitalization, including a craniotomy and further neurological intervention. The facility's documentation indicated that the aggressive act was not substantiated as abuse due to a lack of willful intent, despite the physical evidence and medical opinion linking the injury to the altercation. The facility's abuse policy defined physical abuse as including hitting and slapping, and directed that residents should not be subjected to abuse by anyone, including other residents. Despite this, the facility did not substantiate the incident as abuse and failed to implement effective supervision or interventions to prevent the altercation and resulting injury. The monitoring interventions for the aggressive resident were discontinued prior to the incident, and the facility did not identify or implement additional interventions following the altercation that led to the severe injury.
Failure to Develop Care Plan for Anticoagulant Use and Bleeding Risk
Penalty
Summary
A deficiency was identified when a resident with atrial fibrillation, severe cognitive impairment, and a pacemaker was admitted to the facility while receiving anticoagulant medications, specifically Eliquis and Plavix. Physician orders directed the administration of these medications for atrial fibrillation, and the resident's quarterly MDS assessment confirmed ongoing use of anticoagulants. Despite these factors, the facility failed to develop a comprehensive care plan addressing the use of Eliquis and Plavix and the associated risk of bleeding for this resident. Record review and staff interviews revealed that there was no care plan in place for the risk of bleeding related to anticoagulant use, as required by facility policy. The Director of Nursing and the MDS Coordinator both acknowledged that a care plan should have been created but was not, citing a change in the electronic medical record system and oversight as contributing factors. The facility's care plan policy mandates the development of a person-centered plan of care within seven days of completing the MDS and CAA's, but this was not followed in this case.
Failure to Provide Adequate Supervision for Resident with Aggressive Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent accident hazards for a resident with a known history of aggressive behaviors toward others. The resident, who had diagnoses including anxiety and schizophrenia and demonstrated moderate cognitive impairment, had a documented pattern of resident-to-resident altercations. The care plan for this resident included interventions such as every 15-minute checks, medication administration, and staff intervention when agitation escalated. Despite these interventions, the resident was involved in multiple incidents of physical aggression toward other residents, with care plan updates following each event. Monitoring was discontinued by psychiatry shortly before the most recent incident. Another resident, who had severe cognitive impairment, required assistance with mobility and communication, and was on anticoagulant therapy, became the victim of an unwitnessed physical altercation. This resident was struck in the face by the aggressive resident, resulting in a laceration and subsequent hospital admission for a subdural hematoma. The incident was not witnessed by staff, and the facility's documentation indicated that the aggressive resident's monitoring had been discontinued prior to the event. The injured resident required intensive medical intervention, including a craniotomy and embolization, and remained hospitalized at the time of the survey. Interviews and record reviews confirmed that the aggressive resident admitted to hitting others in the past and in this incident. The facility's investigation did not substantiate abuse, citing lack of willful intent, but did not address whether adequate supervision was provided to prevent the injury. The facility's policy on close observation identified risk factors for harm, including impulsivity and impaired judgment, which were present in the aggressive resident. The deficiency centers on the facility's failure to maintain adequate supervision and implement effective interventions to prevent resident-to-resident altercations and resulting injuries.
Failure to Ensure Timely Physician Review and Order Renewal
Penalty
Summary
The facility failed to ensure that two residents with significant psychiatric and cognitive diagnoses received timely physician reviews and order renewals as required. For both residents, clinical record review showed that physician orders were not signed or renewed for a period of 127 days, despite the facility's 60-day schedule for such reviews. The residents had care plans addressing their mental health and behavioral needs, and both were identified as having moderate cognitive impairment. Documentation revealed that the last physician orders were signed in early November, with no further signatures until early March of the following year. Interviews with the Director of Nursing Services (DNS) and the Medical Director confirmed that the required physician order reviews and signatures were not completed within the mandated timeframe. The DNS was unable to provide documentation or an explanation for the lapse, and the Medical Director acknowledged being behind in signing orders, noting a transition to electronic signatures during the period in question. The facility was also unable to provide a policy regarding medical visits when requested by the surveyor.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with vascular dementia and schizophrenia, who was severely cognitively impaired and dependent for wheelchair mobility, was physically abused by another resident diagnosed with dementia, paranoid schizophrenia, and schizoaffective disorder. The incident occurred when the second resident, who had a history of physical aggression and prior altercations, approached the first resident in the hallway and slapped the left side of their face. This act was witnessed by a non-staff member and a nursing assistant, with the latter observing the aggressor slap the victim a second time. The victim was found with facial redness as a result of the incident. Prior to the event, the aggressive resident had refused medications and was on a waitlist for in-patient psychiatric evaluation, with ongoing psychiatric follow-up and 15-minute checks in place. Despite a documented history of similar altercations, the facility failed to prevent the physical abuse, as required by their abuse policy, which prohibits residents from being subjected to abuse by anyone, including other residents. The facility's documentation and staff interviews confirmed the physical contact and the resident's history of aggression, but did not consider the contact willful.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to adequately document and address grievances raised by the resident council, as evidenced by the review of resident council minutes and interviews with staff. From May to September 2024, residents expressed concerns about staff not properly folding or hanging cleaned clothing, staff using cellphones while providing care, and residents not being able to choose when to be put back to bed. Although the facility documented a resolution in June 2024 to provide staff education on these issues, the concern about cellphone usage was raised again in August 2024, indicating that the issue was not fully resolved. Interviews with the Recreation Director, Staff Development Nurse, and former Director of Nursing Services revealed a lack of communication and follow-through on staff education regarding the concerns raised. The Staff Development Nurse was unaware of the need for education on these issues, and the former Director of Nursing Services could not recall whether she communicated the need for staff education to the Staff Development Nurse. The facility's policy requires department heads to address issues raised at resident council meetings, but the documentation and follow-up on these concerns were insufficient, leading to repeated grievances.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving resident-to-resident altercations. Resident #30, diagnosed with dementia, anxiety, and schizophrenia, was involved in an altercation with Resident #32, who has alcohol-induced dementia and anxiety disorder. Resident #32 threw a chair at Resident #30, resulting in a skin tear and pain. Despite interventions in place to manage behaviors, the facility did not prevent the incident, indicating a failure to ensure residents were free from abuse. Another incident involved Resident #31, who has vascular dementia and major depressive disorder, being hit in the face by Resident #32. Although Resident #31 did not sustain visible injuries, the altercation highlights the facility's inability to prevent aggressive interactions between residents. The facility's investigation did not substantiate the incident as abuse, citing the residents' confusion, but the event still reflects a deficiency in protecting residents from harm. A third incident involved Resident #112, who has vascular dementia and anxiety disorder, physically assaulting Resident #31. Resident #112 slapped, punched, and kicked Resident #31, who complained of pain and had visible scratches. Despite the facility's policy prohibiting abuse, these incidents demonstrate a failure to maintain a safe environment for residents, as evidenced by repeated aggressive interactions and inadequate supervision or intervention to prevent such occurrences.
Failure to Update Care Plans After Resident Altercations
Penalty
Summary
The facility failed to ensure that the care plans for three residents were reviewed and revised following incidents of resident-to-resident altercations. Resident #30, who had diagnoses including dementia, anxiety, and schizophrenia, was involved in an altercation where another resident threw a chair, resulting in a skin tear. Despite this incident, Resident #30's care plan was not updated to reflect the altercation or the interventions put in place to support and protect the resident. Interviews with the Director of Nursing Services (DNS) and social workers revealed a lack of clarity and responsibility in updating the care plan. Resident #31, diagnosed with vascular dementia and major depressive disorder, was struck on the head by another resident while seated in a wheelchair. Although the incident was documented, Resident #31's care plan was not updated to include the altercation or any interventions to ensure the resident's safety. The DNS and social workers acknowledged the oversight and identified that the care plan should have included specific interventions to address the incident. Resident #32, with a history of alcohol-induced dementia and anxiety disorder, was involved in multiple altercations with other residents. Despite these incidents, Resident #32's care plan did not reflect the altercations or the interventions implemented, such as room changes and psychiatric evaluations. Additionally, Resident #59, who was admitted with diagnoses including major depressive disorder and schizoaffective disorder, did not have an interdisciplinary care plan meeting conducted after admission, and there was no documentation of the resident or their conservator being involved in the care planning process.
Failure to Review and Document Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were reviewed by the provider and included in the resident's clinical chart. This deficiency was identified during a review of the clinical record, facility policy/procedures, and interviews concerning a resident with diagnoses including traumatic brain injury, vascular dementia, and anxiety disorder. The resident's care plan indicated participation in a Behavioral Health Program and monitoring for psychotropic medication side effects. However, the facility did not have an established policy and procedure for processing pharmacy recommendations. The pharmacy progress notes indicated that drug regimen reviews were completed on several occasions, with recommendations made to the provider. However, the clinical chart failed to include these pharmacy reviews and recommendations, as well as lab results for the resident. Interviews with the Director of Nursing Services (DNS) and Regional Clinical Director revealed that the recommendations were not all present in the charts, and the facility was in the process of revising the process for handling pharmacy recommendations. The process involved emailing recommendations to the DNS and Assistant Director of Nursing Services (ADNS), who would then print, copy, and provide them to the Advanced Practice Registered Nurse (APRN) for review and signature. Despite this process, some recommendations were not signed by the provider, and lab results were missing from the chart. The APRN acknowledged that drug regimen reviews were placed in her inbox and addressed, sometimes with verbal orders or written on the Physician Order sheets. However, the APRN was only notified of certain drug regimen reviews on the day of the interview and subsequently placed orders for necessary tests. The facility's policy for chart order and retention guidelines required that pharmacy recommendations be included in the resident's chart for the current year, but the facility did not provide a policy for processing these reviews.
Failure to Provide Dental Services to Resident
Penalty
Summary
The facility failed to ensure that a resident, who was admitted with multiple fractures and required total dependence for oral hygiene, received necessary dental services. The resident was identified as having obvious or likely cavities or broken teeth upon admission. Despite complaints of dental pain and orders for a dental evaluation and chlorhexidine mouthwash, there was no documentation of the resident being seen by a dentist or hygienist. The process for scheduling dental appointments involved the nurse who noted the physician's order contacting the unit secretary, who would then arrange the appointment. However, the unit secretary reported not receiving any requests for a dental referral for the resident. Interviews with staff, including the APRN and LPNs, revealed a breakdown in communication and follow-up, resulting in the resident not receiving the necessary dental care. The facility's policy required dental evaluations to be performed by qualified professionals, but the resident was not seen by the dentist or hygienist during their visits to the facility. The failure to ensure the resident received dental services as ordered highlights a deficiency in the facility's process for managing and following through on physician orders.
Failure to Conduct Annual Water Management Plan Meeting
Penalty
Summary
The facility failed to conduct an annual water management plan meeting as required by their policy. The review of the facility's Water Management Plan for 2023 to 2024, conducted with the Director of Maintenance, revealed that the meeting to review the updated and revised plan was not held. The safety committee meeting minutes indicated that the water management meeting was scheduled for July 12, 2024, but it was not conducted. The Director of Maintenance admitted to losing track of time, resulting in the meeting not being held as planned. Further interviews with the administration confirmed that the water management meeting was not completed. The facility's practice was to document discussions regarding the water management plan in the safety committee meeting minutes, which did not occur. The Annual Water Management Plan Revision and Updates provided by the contracted company required the water committee to meet, review the plan, and record the meeting minutes with attendees' signatures. The facility's policy also required annual updates to environmental assessments, which were not completed due to the missed meeting.
Discrepancy in Resident's Code Status Documentation
Penalty
Summary
The facility failed to ensure that the physician's order accurately reflected the resident's chosen code status for one of the residents reviewed for advance directives. Resident #377, who was cognitively intact and had diagnoses including osteomyelitis, viral hepatitis C, and major depressive disorder, had elected a Do Not Resuscitate (DNR) status. This was documented in the Advance Directives/Code Status Consent form and signed by APRN #1. However, the physician's order in the clinical record incorrectly indicated a full code status, which contradicts the resident's expressed wishes. The discrepancy was identified during an interview with the Charge Nurse (LPN #5), who noted that the physician's order and the electronic health record indicated a full code, while the advance directive/code status consent form indicated DNR. APRN #1 acknowledged the error, stating that although she reviewed and signed the order for full code, it was done in error and should have reflected the resident's DNR status. The facility's Code Status policy requires that the attending physician document the resident's preferred status in the clinical record, which was not accurately done in this case.
Failure to Obtain Conservator Consent for Admission
Penalty
Summary
The facility failed to implement its admissions policy for a resident who was admitted with diagnoses including major depressive disorder, schizoaffective disorder, polyneuropathy, and extrapyramidal symptoms. The resident was identified as conserved, yet the facility did not complete necessary admission forms, such as the behavioral program unit resident review and behavioral health program individualized assessment. Additionally, the facility did not contact the resident's conservator to obtain required consents for admission, including consent to treat and consent for residing on a secured unit. Interviews with facility staff, including the Regional Clinical Director, social workers, and the Director of Nursing Services, revealed that the responsibility for obtaining the conservator's signature on admission paperwork was not fulfilled. The conservator was unaware of the resident's admission and had not been contacted by the facility. The facility's admission policy required the completion of admission documentation within 24 hours and identified specific consents to be signed, which were not obtained in this case.
Failure to Verify Admission Orders and Central Line Care
Penalty
Summary
The facility failed to ensure that admission orders for a resident were verified prior to administration, and did not ensure proper care and treatment for a central line catheter. The resident, who was admitted with diagnoses including osteomyelitis, viral hepatitis C, and major depressive disorder, had a peripherally inserted central catheter (PICC) upon admission. The hospital discharge medications and care instructions were not verified with the provider at the time of admission, leading to a lack of proper documentation and verification of orders in the resident's chart. Observations revealed that the resident was self-propelling in a wheelchair while an antibiotic was infusing via the PICC line, which was identified as a non-valve catheter. The medication administration record showed that several medications were administered from the time of admission without proper verification of orders. Interviews with various staff members, including the nursing supervisor, APRN, and infection preventionist, indicated a lack of communication and responsibility for verifying the admission orders. The orders were not transcribed onto the paper physician's order sheet or confirmed with the attending physician as required by facility policy. The facility's policy on physician orders transcription and central line catheter protocol was not followed, resulting in the deficiency. The central line catheter protocol required specific flushing procedures and care, which were not documented or verified. The DNS and ADNS were aware of the issue but did not ensure that the orders were properly documented and verified at the time of admission, leading to a delay in proper care and treatment for the resident.
Lack of Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure a physician's order was in place for the use of oxygen therapy for a resident with multiple health conditions, including end-stage renal disease, chronic obstructive pulmonary disease, anxiety, and heart failure. The resident, who was cognitively intact and required moderate assistance with daily activities, was observed using oxygen at 2 liters via nasal cannula without a corresponding physician's order documented in the medical record. The care plan indicated the resident was at risk for breathing problems and included interventions such as providing oxygen as needed, but the quarterly MDS assessment did not reflect the use of oxygen. During an interview, an LPN confirmed that there should be an order for oxygen, as the resident typically used it after returning from dialysis. However, the LPN was unable to locate a physician's order for oxygen in the resident's medical records, including the medication administration record (MAR) and treatment administration record (TAR). The facility's policies required that prescribers' medication orders be accurately transcribed and executed in a timely manner, and that a physician's order be verified for oxygen administration. The deficiency was identified when a new order for oxygen was documented only after surveyor inquiry.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to administer pain medication in a timely manner to Resident #115, who was experiencing severe pain due to a gunshot wound. The resident was cognitively intact and required assistance with daily activities, using a wheelchair for mobility. The care plan included administering pain medication as ordered and addressing breakthrough pain. Despite having physician orders for Oxycodone and Ibuprofen, the resident did not receive the medication promptly on the evening of 8/14/24. On that evening, the resident rang the call bell multiple times requesting pain medication, but the nurse, LPN #3, was not responsive. The nursing assistant, NA#1, informed the nurse twice about the resident's request, but the nurse seemed annoyed and did not administer the medication. The resident waited over two and a half hours and eventually fell while trying to move due to intense pain. The nurse was on break and did not return until later, at which point she refused to administer the medication due to the resident's frustration. The facility's documentation showed that the medication was not signed off as administered, and the nurse claimed she was unaware of the resident's pain. The Director of Nursing Services (DNS) confirmed that it was the nurse's responsibility to assess and administer medication when informed of a resident's pain. The facility's policies on medication administration and pain management were not followed, leading to the resident's grievance and the deficiency finding.
Failure to Ensure Access to Emergency Medication and Proper Controlled Substance Management
Penalty
Summary
The facility failed to ensure access to emergency supply medication and did not implement a system to account for the receipt, usage, disposition, and reconciliation of medications. Resident #73, who had diagnoses including an unspecified open wound on the left foot, anxiety disorder, and post-traumatic stress disorder, was affected by this deficiency. Upon returning from the hospital, Resident #73 requested Lorazepam 1mg PRN for anxiety, but the medication was not available. This unavailability led to the resident becoming agitated and punching the wall, resulting in an injury. The facility's system for managing controlled substances was inadequate. The nurse on duty, LPN #9, and the supervising RN #5, who was an agency nurse, did not have access to the Omni-cell, which contained emergency medications. Consequently, the medication was borrowed from another resident, which is against policy. The Director of Nursing Services (DNS) acknowledged that the receipt and disposition records for the Lorazepam could not be located, and the facility's policy for handling unavailable medications was not followed. Additionally, the facility's process for receiving and auditing controlled substances was flawed. The ADNS admitted that the yellow Controlled Substance Disposition Record (CSDR) sheets were not properly managed, and the reception area where these records were kept was unsecured. The ADNS was unaware of the proper procedure for conducting controlled substance audits, which should have involved comparing delivery slips with CSDR sheets. The facility's policy required controlled drug audits twice a month, but the ADNS's interpretation of an audit was merely counting the medication carts with the nurses, without verifying the records.
Deficiencies in Medical Record Documentation and Accessibility
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in documentation and accessibility. For Resident #32, who had diagnoses including alcohol-induced dementia and anxiety disorder, the facility did not provide complete documentation of one-to-one observation and every 15-minute checks as ordered by the physician. Despite multiple requests, the facility was unable to locate the necessary flowsheets for the specified period, indicating a lapse in record-keeping and adherence to the facility's policy on close observation documentation. Resident #59, diagnosed with major depressive disorder and schizoaffective disorder, was admitted without the necessary conservator paperwork and signed admission documents. The facility's records lacked documentation of contact with the resident's conservator regarding admission paperwork, including consents for treatment and residency on a secured unit. Interviews revealed that the admission paperwork was not present in the clinical chart, and the social worker had kept the documents in a separate file, contrary to the facility's policy. For Resident #78, who had a diagnosis of diffuse traumatic brain injury and vascular dementia, the facility failed to include pharmacy review recommendations and lab results in the clinical chart. The process for handling pharmacy recommendations was not followed, as the recommendations were not signed by the APRN and were not included in the resident's chart. The facility's policy required that pharmacy recommendations be kept in the chart for at least one year, highlighting a deficiency in the facility's documentation practices.
Failure to Label and Date Food Items
Penalty
Summary
The facility failed to ensure that food items were appropriately labeled and dated when opened or stored, and removed once expired. During a kitchen tour, surveyors observed five brown bags in the walk-in refrigerator without any identifiable information, dates, or resident names. These bags were identified by the Food Service Director (FSD) as lunches prepared for dialysis residents, which should have been labeled and dated with each resident's name. Additionally, four large bins were found, two containing white rice, one of which was undated, and another with powdered thickener that was expired. A bin with flour was also found without a label or date. The facility's Food Storage and Marking policies require that dry food items have a date including the month, date, and year of delivery or a manufacturer's printed Best By/Use by date. The policy also mandates that refrigerated, ready-to-eat, potentially hazardous foods be clearly marked at the time of preparation to indicate the date of preparation and discarded within 72 hours of being opened. The FSD acknowledged that the bins should have been labeled once opened or filled, and the powdered thickener was expired. The failure to adhere to these policies led to the deficiency identified during the survey.
Failure to Document Resident's Refusal of Recovery Services
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with a substance abuse disorder. Resident #2, who was admitted with diagnoses including substance abuse disorder with opioid addiction and cervical spine degeneration, was identified as alert, oriented, and walking independently. The Resident Care Plan (RCP) directed that the resident be encouraged to participate in the facility's substance use recovery services and that refusals should be documented. However, the facility did not document the resident's refusals to attend the Recovery Program groups, as confirmed by interviews with the Director of Social Work (SW #2), the Director of Nursing (DON), and the Clinical Director. The medical record lacked documentation of the offered recovery program groups and the resident's refusals to attend. Interviews with the Director of Social Work, the Director of Nursing, and the Clinical Director revealed that the refusals should have been documented in the social services notes and the medical record. Despite requests, the facility was unable to provide a documentation policy for review during the survey. This failure to document the resident's refusals to participate in the recovery program constitutes a deficiency in maintaining a complete and accurate medical record in accordance with accepted professional standards.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hartford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkville Care Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Avery Nursing Home/noble Building | 1.1 mi | ★★★★★ | 1 | 0 |
| Chelsea Place Care Center Llc | 1.4 mi | ★★★★★ | 8 | 1 |
| West Hartford Health & Rehabilitation Center | 2.5 mi | ★★★★★ | 22 | 0 |
| Saint Mary Home | 2.9 mi | ★★★★★ | 3 | 0 |
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