Lutheran Home at Trinity Oaks

Total Number of Beds: 115	Percent of Occupied Beds: 97%
Total Number of Residents: 112	Located Within a Hospital: No
Type of Ownership: Non profit - Church related	Multiple Nursing Homes by Same Owner: Yes
Councils the Nursing Home Participates in: Family & Resident	Medicare/Medicaid: Participating in Medicare and Medicaid
* Details Last Reported on: 05/22/2003

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day: 0.9

Number of LPN/LVN Hours per Nursing Home Resident per Day: 0.48

Number of CNA Hours per Nursing Home Resident per Day: 2.99

Number of Staff Hours per Nursing Home Resident per Day: 4.37

Nursing Home Resident Information**:

Percent of Low-Risk Residents Who Have Pressure Sores: 0%
Percent of Short-Stay Residents With Pressure Sores: 10%
Percent of High-Risk Residents Who Have Pressure Sores: 17%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain: 32%
Percent of Residents Who Have Moderate to Severe Pain: 4%
Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse: 11%
Percent of Residents Who Spend Most of Their Time in Bed or in a Chair: 14%
Percent of Residents Whose Need for Help With Daily Activities Has Increased: 11%
Percent of Residents Who are More Depressed or Anxious: 7%
Percent of Short-Stay Residents With Delirium: 4%
Percent of Residents Who Were Physically Restrained: 5%
Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder: 45%
Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder: 11%
Percent of Residents With a Urinary Tract Infection: 8%
** Details Last Reported on: 5/22/2003

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2001-09-13	2001-09-13	Resident Rights Deficiencies	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
2001-09-13	2001-09-13	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
2001-09-13	2001-11-06	Quality Care Deficiencies	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
2001-09-13	2001-11-06	Pharmacy Service Deficiencies	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
2003-05-22	2003-06-12	Resident Rights Deficiencies	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
2003-05-22	2003-06-12	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
2003-05-22	2003-06-12	Quality Care Deficiencies	Make sure that residents with loss of bladder control receive treatment or service to prevent infections and help get normal bladder control.	Isolated	Minimal harm or potential for actual harm
2003-05-22	2003-06-12	Quality Care Deficiencies	Make sure that each resident's nutritional needs were met.	Isolated	Actual harm
2003-05-22	2003-06-12	Pharmacy Service Deficiencies	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.	Pattern	Minimal harm or potential for actual harm
2003-05-22	2003-06-12	Pharmacy Service Deficiencies	Make sure that the pharmacist reports anything unusual to the doctor on duty and the director of nursing.	Pattern	Minimal harm or potential for actual harm
2003-05-22	0000-00-00	Deficiencies Reported Between Inspections	Comply with program requirements between annual inspections; although it corrected these problems before the most recent inspection.	Isolated	Immediate jeopardy to resident health or safety

*** All violations listed are based on federal government records.