TRINITY HOSPITAL

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 California 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

Short-Term Stay Preventive Actions

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 04/14/2011.

Administration

Give or Get Lab Tests to Meet the Needs of Residents. Inspection Date: 04/15/2010 Correction Date: 05/20/2010
Train All Employees on What to Do in an Emergency. Inspection Date: 04/15/2010 Correction Date: 05/20/2010
Have a Detailed, Written Plan for Disasters and Emergencies. Inspection Date: 04/14/2011 Correction Date: 05/16/2011

Environmental

Provide Bedrooms That Hold No More Than 4 Residents Per Room. Inspection Date: 04/15/2009 Correction Date: 05/12/2009
Have a Program to Keep Infection from Spreading. Inspection Date: 04/15/2010 Correction Date: 05/20/2010
Provide Bedrooms That Hold No More Than 4 Residents Per Room. Inspection Date: 04/15/2010 Correction Date: 05/20/2010
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Inspection Date: 04/14/2011 Correction Date: 05/16/2011
Have a Program to Keep Infection from Spreading. Inspection Date: 04/14/2011 Correction Date: 05/16/2011
Provide Bedrooms That Hold No More Than 4 Residents Per Room. Inspection Date: 04/14/2011 Correction Date: 01/01/1900
Make Sure That the Nursing Home Area is Safe, Easy to Use, Clean and Comfortable. Inspection Date: 04/14/2011 Correction Date: 05/16/2011

Mistreatment

Keep Each Resident Free from Physical Restraints, Unless Needed for Medical Treatment. Inspection Date: 04/15/2009 Correction Date: 05/12/2009

Nutrition and Dietary

Prepare Food That is Nutritional, Appetizing, Tasty, Attractive, Well-Cooked, and at the Right Temperature. Inspection Date: 04/15/2009 Correction Date: 05/12/2009
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 04/15/2009 Correction Date: 05/12/2009
Make Sure That Residents Are Well Nourished. Inspection Date: 04/15/2010 Correction Date: 05/20/2010
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 04/15/2010 Correction Date: 05/20/2010
Hire a Qualified Dietician. Inspection Date: 04/14/2011 Correction Date: 05/16/2011
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 04/14/2011 Correction Date: 05/16/2011

Pharmacy Service

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: 04/15/2010 Correction Date: 05/20/2010
At Least Once a Month, Have a Licensed Pharmacist Check the Drugs That Each Resident Takes. Inspection Date: 04/15/2010 Correction Date: 05/20/2010
Properly Mark Drugs and Other Similar Products. Inspection Date: 04/15/2010 Correction Date: 05/20/2010
At Least Once a Month, Have a Licensed Pharmacist Check the Drugs That Each Resident Takes. Inspection Date: 04/14/2011 Correction Date: 05/16/2011

Quality Care

Develop/Implement Required Procedures for the Administration of Immunizations. Inspection Date: 04/15/2009 Correction Date: 05/12/2009

Resident Assessment

Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured. Inspection Date: 04/15/2010 Correction Date: 05/20/2010
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured. Inspection Date: 04/14/2011 Correction Date: 05/16/2011

Resident Rights

Allow Residents to Easily See the Results of the Nursing Home's Most Recent Survey. Inspection Date: 04/15/2010 Correction Date: 05/20/2010
Allow Residents to Easily See the Results of the Nursing Home's Most Recent Survey. Inspection Date: 04/14/2011 Correction Date: 05/16/2011
Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect. Inspection Date: 04/14/2011 Correction Date: 05/16/2011

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 Hospital 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 04/20/2011.

Automatic Sprinkler Systems

Automatic Sprinkler Systems That Have Been Maintained in Working Order. Inspection Date: 04/20/2011 Correction Date: 05/12/2011
Back-Up Procedures in Place for a Faulty Automatic Sprinkler System. Inspection Date: 04/20/2011 Correction Date: 05/12/2011

Electrical

Weekly Inspections and Monthly Testing of Generators. Inspection Date: 04/20/2010 Correction Date: 05/11/2010
Properly Installed Electrical Wiring and Equipment. Inspection Date: 04/20/2010 Correction Date: 05/11/2010
Weekly Inspections and Monthly Testing of Generators. Inspection Date: 04/20/2011 Correction Date: 05/12/2011
Properly Installed Electrical Wiring and Equipment. Inspection Date: 04/20/2011 Correction Date: 05/12/2011

Emergency Plans and Fire Drills

Record of Quarterly Fire Drills for Each Shift Under Varying Conditions. Inspection Date: 04/20/2010 Correction Date: 05/11/2010

Fire Alarm Systems

An Approved Back-Up Procedure for a Faulty Fire Alarm System. Inspection Date: 04/20/2011 Correction Date: 05/12/2011

Furnishings and Decorations

Exits That Are Free from Obstructions and Can Be Used at All Times. Inspection Date: 04/20/2010 Correction Date: 05/11/2010
Exits That Are Free from Obstructions and Can Be Used at All Times. Inspection Date: 04/20/2011 Correction Date: 05/12/2011
Restrictions on the Use of Highly Flammable Materials. Inspection Date: 04/20/2011 Correction Date: 05/12/2011

Hazardous Area

Properly Installed Hallway Dispensers for Alcohol-Based Hand Rub. Inspection Date: 05/05/2009 Correction Date: 05/26/2009
Properly Installed Hallway Dispensers for Alcohol-Based Hand Rub. Inspection Date: 04/20/2011 Correction Date: 05/12/2011

Medical Gases and Anesthetizing Areas

Proper Medical Gas Storage and Administration Areas. Inspection Date: 04/20/2010 Correction Date: 05/11/2010