Trinity Mission Health and Rehab

Total Number of Beds: 111	Percent of Occupied Beds: 62%
Total Number of Residents: 69	Located Within a Hospital: No
Type of Ownership: For profit - Partnership	Multiple Nursing Homes by Same Owner: No
Councils the Nursing Home Participates in: Resident	Medicare/Medicaid: Participating in Medicare and Medicaid
* Details Last Reported on: 01/16/2004

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day: 0.6

Number of LPN/LVN Hours per Nursing Home Resident per Day: 1.3

Number of CNA Hours per Nursing Home Resident per Day: 1.97

Number of Staff Hours per Nursing Home Resident per Day: 3.87

Nursing Home Resident Information**:

Percent of Short-Stay Residents With Pressure Sores: 28%
Percent of High-Risk Residents Who Have Pressure Sores: 30%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain: 7%
Percent of Residents Who Have Moderate to Severe Pain: 1%
Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse: 17%
Percent of Residents Who Spend Most of Their Time in Bed or in a Chair: 0%
Percent of Residents Whose Need for Help With Daily Activities Has Increased: 18%
Percent of Residents Who are More Depressed or Anxious: 25%
Percent of Short-Stay Residents With Delirium: 13%
Percent of Residents Who Were Physically Restrained: 7%
Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder: 54%
Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder: 1%
Percent of Residents With a Urinary Tract Infection: 6%
** Details Last Reported on: 1/16/2004

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2002-01-11	2002-02-09	Resident Rights Deficiencies	Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care.	Isolated	Minimal harm or potential for actual harm
2002-01-11	2002-02-09	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Potential for minimal harm
2002-01-11	2002-02-09	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
2002-01-11	2002-02-09	Environmental Deficiencies	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
2002-01-11	2002-02-09	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.	Isolated	Minimal harm or potential for actual harm
2002-01-11	2002-02-09	Environmental Deficiencies	Make sure that staff members wash their hands when needed.	Isolated	Minimal harm or potential for actual harm
2002-01-11	2002-02-09	Administration Deficiencies	Be administered in a way that leads to the highest possible level of well being for each resident.	Widespread	Minimal harm or potential for actual harm
2002-01-11	2002-02-09	Administration Deficiencies	Hold committee meetings every 3 months to review and ensure quality in the nursing home.	Pattern	Minimal harm or potential for actual harm
2002-12-06	2003-01-30	Mistreatment Deficiencies	Protect residents from mistreatment, neglect, and/or theft of personal property.	Isolated	Minimal harm or potential for actual harm
2002-12-06	2003-01-30	Quality Care Deficiencies	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
2002-12-06	2003-01-30	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
2002-12-06	2003-01-30	Quality Care Deficiencies	Make sure that each resident gets help to keep vision and hearing.	Isolated	Minimal harm or potential for actual harm
2004-01-16	2004-02-26	Resident Rights Deficiencies	Keep each resident's personal and medical records private and confidential.	Pattern	Potential for minimal harm
2004-01-16	2004-02-29	Mistreatment Deficiencies	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.	Pattern	Minimal harm or potential for actual harm
2004-01-16	2004-02-20	Mistreatment Deficiencies	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
2004-01-16	2004-02-16	Resident Rights Deficiencies	Provide care for each resident in a way that keeps or builds the resident's quality of life.	Pattern	Potential for minimal harm
2004-01-16	2004-03-09	Environmental Deficiencies	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
2004-01-16	2004-03-09	Resident Assessment Deficiencies	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
2004-01-16	2004-03-05	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
2004-01-16	2004-03-09	Quality Care Deficiencies	Make sure each resident is being watched and has assistance devices when needed, to prevent accidents.	Isolated	Actual harm
2004-01-16	2004-03-09	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
2004-01-16	2004-03-09	Resident Assessment Deficiencies	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Pattern	Minimal harm or potential for actual harm
2004-01-16	2004-03-09	Pharmacy Service Deficiencies	Make sure that the pharmacist reports anything unusual to the doctor on duty and the director of nursing.	Isolated	Minimal harm or potential for actual harm
2004-01-16	2004-03-09	Environmental Deficiencies	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm

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