TRINITY VILLAGE
Address
7500 W DEAN RD
MILWAUKEE, WI 53223
(414) 371-7300
Nursing Home Ratings
| Health Inspections | |
| Quality Measures | |
| Nursing Staff | |
| R.N. Staff Only | |
| Overall Rating | |
Percent of Beds Occupied
73%Number of Residents and Certified Beds
- Residents: 54
- Certified Beds: 74
This Facility Accepts
- Medicare
- Medicaid
Operational Details
- Operated By Non Profit - Corporation
- Offers Only Resident Counseling
- Part of a Continuing Care Retirement Community (CCRC)
- This Facility is Part of a Chain or Franchise
Resident Services
The information below lists services this facility has provided for residents from October through December 2010. During this period, the most common type of service provided was "Ultra-High Rehabilitation". To get a better idea of the types of services that are commonly performed, compare the "Percent of Service Days" column below. These services are based on submitted claims to Medicare and do not provide a complete overview of all the services provided by Trinity Village. For more information read our guide on how nursing facilities are reimbursed, types of services, and ADL index scores.
| Resident Services | Resident Conditions | Percent of Service Days |
Very High Rehabilitation Plus Extensive Services
- At least one rehabilitation discipline five days/week
- Tracheostomy care
- Ventilator or respirator
- Isolation for active infectious disease while a resident
- Activities of Daily Living (ADL) score of 2 or more
| ADL Index Range: 2-10 | 5.8% |
| Total Percent: | 5.8% |
Ultra-High Rehabilitation
- At least one rehabilitation discipline five days/week
- A second rehabilitation discipline three days/week
| ADL Index Range: 11-16 | 26.6% |
| ADL Index Range: 6-10 | 16.0% |
| ADL Index Range: 0-5 | 25.6% |
| Total Percent: | 68.3% |
Very High Rehabilitation
- At least one rehabilitation discipline five days/week
| ADL Index Range: 6-10 | 11.3% |
| ADL Index Range: 0-5 | 7.2% |
| Total Percent: | 18.4% |
High Rehabilitation
- At least one rehabilitation discipline five days/week
| ADL Index Range: 11-16 | 4.8% |
| ADL Index Range: 6-10 | 0.3% |
| Total Percent: | 5.1% |
Medium Rehabilitation
- Five days any combination of three rehabilitation disciplines
| ADL Index Range: 6-10 | 0.7% |
| ADL Index Range: 0-5 | 1.7% |
| Total Percent: | 2.4% |
Rating Details For Trinity Village
Nursing Staff - 
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.
| Nursing Hours Per Resident Per Day | Reported | Expected |
| Registered Nurse (RN) Hours | 53 Minutes | 1 Hour and 3 Minutes |
| Licensed Practical/Vocational Nurse (LPN/LVN) Hours | 1 Hour and 23 Minutes | 34 Minutes |
| Certified Nursing Assistant (CNA) Hours | 2 Hours and 53 Minutes | 2 Hours and 25 Minutes |
| Total Licensed Nurse Hours | 2 Hours and 15 Minutes | 1 Hour and 38 Minutes |
| Total Nurse Hours | 5 Hours and 8 Minutes | 4 Hours and 2 Minutes |
Quality of Care -
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 Wisconsin are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.
| This Facility | Wisconsin Average |
Long-Term Stay Preventive Actions
| Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season | 90-100% | 94% |
| Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 90-100% | 95% |
Long-Term Stay Deficiencies
| Percent of Long-Stay Residents Who Are More Depressed or Anxious | 5% | 18% |
| Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased | 17% | 14% |
| Percent of Long-Stay Residents Who Lose Too Much Weight | 6% | 8% |
| Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair | - | 3% |
| Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse | 12% | 11% |
| Percent of Long-Stay Residents Who Had a Urinary Tract Infection | 6% | 8% |
| Percent of Long-Stay Residents Who Have Moderate to Severe Pain | 2% | 4% |
| Percent of High-Risk Long-Stay Residents Who Have Pressure Sores | 13% | 8% |
| Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder | 4% | 7% |
| Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder | 66% | 49% |
| Percent of Long-Stay Residents Who Were Physically Restrained | - | 3% |
| Percent of Low-Risk Long-Stay Residents Who Have Pressure Sores | - | 3% |
Short-Term Stay Preventive Actions
| Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season | 90-100% | 90% |
| Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 90-100% | 92% |
Short-Term Stay Deficiencies
| Percent of Short-Stay Residents Who Had Moderate to Severe Pain | 18% | 26% |
| Percent of Short-Stay Residents Who Have Delirium | - | 3% |
| Percent of Short-Stay Residents Who Have Pressure Sores | 11% | 10% |
Health Inspection Details -
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 05/20/2011.
Degree of Harm
- Potential for Minimal Harm
- Minimal Harm or Potential for Harm
- Resident Harmed
- Immediate Jeopardy to Resident Health
Residents Affected
- Isolated
- Some Residents
- Many Residents
| Deficiencies Found By Inspectors | Degree of Harm | Residents Affected |
Environmental
Provide Needed Housekeeping and Maintenance.
|  |  |
Mistreatment
Keep Each Resident Free from Physical Restraints, Unless Needed for Medical Treatment.
| | |
Nutrition and Dietary
Store, Cook, and Give out Food in a Safe and Clean Way.
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Pharmacy Service
Keep the Rate of Medication Errors (Wrong Drug, Wrong Dose, Wrong Time) to Less Than 5%.
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Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly.
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Quality Care
Give Professional Services That Follow Each Resident's Written Care Plan.
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Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores.
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Resident Assessment
Make Sure All Assessments Are Accurate, Coordinated by an Rn, Done by the Right Professional, and Are Signed by the Person Completing Them.
|  |  |
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured.
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Deficiencies from Complaints and Incidents
The table below lists incident reports by the nursing staff or administration for Trinity Village, as well as complaints by residents or their family in the previous three years.
Degree of Harm
- - Potential for Minimal Harm
- - Minimal Harm or Potential for Harm
- - Resident Harmed
- - Immediate Jeopardy to Resident Health
Residents Affected
- - Isolated
- - Some Residents
- - Many Residents
| Formal Complaints | Degree of Harm | Residents Affected |
Environmental
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Have a Program to Keep Infection from Spreading.
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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.
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Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property.
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Resident Rights
Provide Services to Meet the Needs and Preferences of Each Resident.
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Fire Safety
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 Village 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 05/23/2011.
Degree of Harm
- - Potential for Minimal Harm
- - Minimal Harm or Potential for Harm
- - Resident Harmed
- - Immediate Jeopardy to Resident Health
Residents Affected
- - Isolated
- - Some Residents
- - Many Residents
| Deficiencies Found By Inspectors | Degree of Harm | Residents Affected |
Automatic Sprinkler Systems
An Approved Automatic Sprinkler System Connected to the Fire Alarm System.
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Back-Up Procedures in Place for a Faulty Automatic Sprinkler System.
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Automatic Sprinkler Systems That Have Been Maintained in Working Order.
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An Approved Automatic Sprinkler System Connected to the Fire Alarm System.
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Automatic Sprinkler Systems That Have Been Maintained in Working Order.
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Building Construction
Approved Construction Type or Materials.
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Building Service Equipment
Properly Protected Cooking Facilities.
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Corridor Walls and Doors
Corridor and Hallway Doors That Block Smoke.
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Corridor and Hallway Doors That Block Smoke.
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Corridors That Are Separated from Common Areas by Walls Constructed to Limit the Passage of Smoke.
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Electrical
Weekly Inspections and Monthly Testing of Generators.
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Properly Installed Electrical Wiring and Equipment.
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Properly Installed Electrical Wiring and Equipment.
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Emergency Plans and Fire Drills
Record of Quarterly Fire Drills for Each Shift Under Varying Conditions.
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Exits and Egress
Exits That Are Accessible at All Times.
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Exits That Are Accessible at All Times.
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Fire Alarm Systems
An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems.
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An Approved Back-Up Procedure for a Faulty Fire Alarm System.
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Furnishings and Decorations
Exits That Are Free from Obstructions and Can Be Used at All Times.
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Illumination and Emergency Power
Emergency Lighting That Can Last at Least 1 1/2 Hours.
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Medical Gases and Anesthetizing Areas
Proper Medical Gas Storage and Administration Areas.
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Proper Medical Gas Storage and Administration Areas.
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Smoke Compartmentation and Control
Smoke Barrier Doors That Can Resist Smoke for at Least 20 Minutes.
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Vertical Openings
Exit Doors That Are Held Open by Devices That Will Automatically Close on the Activation of a Fire Alarm or Smoke Detectors.
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