TRINITY ST ELIZABETH HEALTH SERVICES, INC

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Oregon are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

Long-Term Stay Preventive Actions

Long-Term Stay Deficiencies

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 10/12/2010.

Administration

Keep Accurate and Appropriate Medical Records. Inspection Date: 11/06/2009 Correction Date: 12/26/2009
Post Nurse Staffing Information. Inspection Date: 10/12/2010 Correction Date: 11/09/2010
Keep Accurate and Appropriate Medical Records. Inspection Date: 10/12/2010 Correction Date: 11/09/2010
Train All Employees on What to Do in an Emergency. Inspection Date: 10/12/2010 Correction Date: 11/09/2010

Environmental

Make Sure That the Nursing Home Area is Safe, Easy to Use, Clean and Comfortable. Inspection Date: 10/08/2008 Correction Date: 11/26/2008

Mistreatment

1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents. Inspection Date: 10/08/2008 Correction Date: 11/26/2008
Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property. Inspection Date: 10/12/2010 Correction Date: 11/09/2010

Pharmacy Service

Properly Mark Drugs and Other Similar Products. Inspection Date: 10/08/2008 Correction Date: 11/26/2008
At Least Once a Month, Have a Licensed Pharmacist Check the Drugs That Each Resident Takes. Inspection Date: 11/06/2009 Correction Date: 12/26/2009
1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects. Inspection Date: 10/12/2010 Correction Date: 11/09/2010

Quality Care

Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible. Inspection Date: 11/06/2009 Correction Date: 12/26/2009
Give Professional Services That Meet a Professional Standard of Quality. Inspection Date: 10/12/2010 Correction Date: 11/09/2010
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible. Inspection Date: 10/12/2010 Correction Date: 11/09/2010
Make Sure That Residents Who Cannot Care for Themselves Receive Help with Eating/Drinking, Grooming and Hygiene. Inspection Date: 10/12/2010 Correction Date: 11/09/2010
Make Sure That Residents with Reduced Range of Motion Get Proper Treatment and Services to Increase Range of Motion. Inspection Date: 10/12/2010 Correction Date: 11/09/2010

Resident Assessment

1) Develop a Complete Care Plan Within 7 Days of Each Resident's Admission; 2) Prepare a Care Plan with the Care Team, Including the Primary Nurse, Doctor, Resident or Resident's Family or Representative; or 3) Check and Update the Care Plan. Inspection Date: 10/08/2008 Correction Date: 11/26/2008
Make Sure That Doctors Visit Residents Regularly, As Required. Inspection Date: 10/08/2008 Correction Date: 11/26/2008
Make Sure That Doctors See a Resident's Plan of Care at Every Visit and Make Notes About Progress and Orders in Writing. Inspection Date: 11/06/2009 Correction Date: 12/26/2009
Make Sure That Doctors Visit Residents Regularly, As Required. Inspection Date: 11/06/2009 Correction Date: 12/26/2009
Make Sure That Doctors See a Resident's Plan of Care at Every Visit and Make Notes About Progress and Orders in Writing. Inspection Date: 10/12/2010 Correction Date: 11/09/2010
Make Sure That Doctors Visit Residents Regularly, As Required. Inspection Date: 10/12/2010 Correction Date: 11/09/2010

Resident Rights

Immediately Tell the Resident, Doctor, and a Family Member If: the Resident is Injured, There is a Major Change in Resident's Physical/Mental Health, There is a Need to Alter Treatment Significantly, or the Resident Must Be Transferred or Discharged. Inspection Date: 10/08/2008 Correction Date: 11/26/2008
Keep Each Resident's Personal and Medical Records Private and Confidential. Inspection Date: 10/08/2008 Correction Date: 11/26/2008
Allow Residents to Easily See the Results of the Nursing Home's Most Recent Survey. Inspection Date: 10/08/2008 Correction Date: 11/26/2008
Properly Hold, Secure and Manage Each Resident's Personal Money Which is Deposited with the Nursing Home. Inspection Date: 11/06/2009 Correction Date: 12/26/2009

The table below lists incident reports by the nursing staff or administration for Trinity St Elizabeth Health Services, Inc, as well as complaints by residents or their family in the previous three years.

Environmental

Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Complaint Filed: 10/08/2008 Correction Date: 11/26/2008

Quality Care

Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible. Complaint Filed: 10/08/2008 Correction Date: 11/26/2008

Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Trinity St Elizabeth Health Services, Inc had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 10/12/2010.

Automatic Sprinkler Systems

Automatic Sprinkler Systems That Have Been Maintained in Working Order. Inspection Date: 10/09/2008 Correction Date: 12/04/2008
Automatic Sprinkler Systems That Have Been Maintained in Working Order. Inspection Date: 11/05/2009 Correction Date: 12/26/2009
Automatic Sprinkler Systems That Have Been Maintained in Working Order. Inspection Date: 10/12/2010 Correction Date: 12/01/2010

Building Construction

Approved Construction Type or Materials. Inspection Date: 10/09/2008 Correction Date: 12/04/2008
Approved Construction Type or Materials. Inspection Date: 11/05/2009 Correction Date: 12/26/2009
A Two-Hour-Resistant Firewall in Common Walls. Inspection Date: 10/12/2010 Correction Date: 12/01/2010

Building Service Equipment

Restrictions on the Use of Portable Space Heaters. Inspection Date: 10/12/2010 Correction Date: 12/01/2010

Corridor Walls and Doors

Corridors That Are Separated from Common Areas by Walls Constructed to Limit the Passage of Smoke. Inspection Date: 10/09/2008 Correction Date: 12/04/2008
Corridor and Hallway Doors That Block Smoke. Inspection Date: 10/09/2008 Correction Date: 12/04/2008
Corridor and Hallway Doors That Block Smoke. Inspection Date: 10/12/2010 Correction Date: 12/01/2010

Electrical

Properly Installed Electrical Wiring and Equipment. Inspection Date: 10/09/2008 Correction Date: 12/04/2008
Properly Installed Electrical Wiring and Equipment. Inspection Date: 11/05/2009 Correction Date: 12/26/2009
Properly Installed Electrical Wiring and Equipment. Inspection Date: 10/12/2010 Correction Date: 12/01/2010

Emergency Plans and Fire Drills

Did Not Have a Written Emergency Evacuation Plan. Inspection Date: 11/05/2009 Correction Date: 12/26/2009
Record of Quarterly Fire Drills for Each Shift Under Varying Conditions. Inspection Date: 10/12/2010 Correction Date: 12/01/2010

Exit and Exit Access

At Least Two Remote Exits on Each Floor or Fire Section of the Building. Inspection Date: 11/05/2009 Correction Date: 12/26/2009

Exits and Egress

Corridors or Aisles That Are Unobstructed and Are at Least 8 Feet in Width. Inspection Date: 10/09/2008 Correction Date: 01/08/2009
Exits That Are Accessible at All Times. Inspection Date: 10/12/2010 Correction Date: 12/01/2010

Fire Alarm Systems

An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems. Inspection Date: 10/12/2010 Correction Date: 12/01/2010
Properly Maintained Smoke Detectors. Inspection Date: 10/12/2010 Correction Date: 12/01/2010

Furnishings and Decorations

Exits That Are Free from Obstructions and Can Be Used at All Times. Inspection Date: 10/12/2010 Correction Date: 12/01/2010

Hazardous Area

Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System. Inspection Date: 11/05/2009 Correction Date: 12/26/2009

Medical Gases and Anesthetizing Areas

Proper Medical Gas Storage and Administration Areas. Inspection Date: 10/12/2010 Correction Date: 12/01/2010

Miscellaneous

Fire Safety Features Required by Current Fire Safety Codes. Inspection Date: 10/12/2010 Correction Date: 12/01/2010

Smoke Compartmentation and Control

Smoke Barrier Doors That Can Resist Smoke for at Least 20 Minutes. Inspection Date: 11/05/2009 Correction Date: 12/26/2009