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TRINIDAD REHABILITATION AND HEALTHCARE CENTER Inspection Report, Violations & Safety Grade (TRINIDAD, Colorado)

409 BENEDICTA AVE, TRINIDAD, Colorado 81082

Phone: 7198469291

CMS Overall:3/5

Overview & Bed Count

Certified Beds
119
Avg Residents/Day
82.6
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Las Animas
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
Yes

CMS Star Ratings

Overall3/5
Health2/5
Staffing2/5
Quality5/5

Nurse Staffing Check

MetricThis FacilityColorado AvgDifference
RN Hours per Resident per Day0.380.81-0.43
Total Nurse Hours per Resident per Day3.413.69-0.29
CMS Staffing Rating2/53.1/5-
Nursing Staff Turnover33.8%47%-

Health Citation History

40 health citations on record

DateCategoryDescriptionSeverity
2026-02-18Freedom from Abuse, Neglect, and Exploitation DeficienciesProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.E – Moderate Harm Potential
2025-12-05Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential
2025-12-05Resident Assessment and Care Planning DeficienciesSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.D – Moderate Harm Potential
2024-06-05Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2024-06-05Nursing and Physician Services DeficienciesObserve each nurse aide's job performance and give regular training.E – Moderate Harm Potential
2024-06-05Resident Rights DeficienciesAllow resident to participate in the development and implementation of his or her person-centered plan of care.D – Moderate Harm Potential
2024-06-05Resident Rights DeficienciesAllow residents to self-administer drugs if determined clinically appropriate.D – Moderate Harm Potential
2024-06-05Freedom from Abuse, Neglect, and Exploitation DeficienciesProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.D – Moderate Harm Potential
2024-06-05Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential
2024-06-05Quality of Life and Care DeficienciesTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.D – Moderate Harm Potential
2024-06-05Pharmacy Service DeficienciesImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.D – Moderate Harm Potential
2024-06-05Administration DeficienciesArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.D – Moderate Harm Potential
2020-02-05Freedom from Abuse, Neglect, and Exploitation DeficienciesProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.F – Moderate Harm Potential
2020-02-05Freedom from Abuse, Neglect, and Exploitation DeficienciesTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.F – Moderate Harm Potential
2020-02-05Resident Rights DeficienciesNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.F – Moderate Harm Potential
2020-02-05Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2020-02-05Administration DeficienciesConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.F – Moderate Harm Potential
2020-02-05Nursing and Physician Services DeficienciesDesignate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.F – Moderate Harm Potential
2020-02-05Administration DeficienciesHave an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.F – Moderate Harm Potential
2020-02-05Administration DeficienciesHave a plan that describes the process for conducting QAPI and QAA activities.F – Moderate Harm Potential
2020-02-05Resident Rights DeficienciesHonor the resident's right to manage his or her financial affairs.E – Moderate Harm Potential
2020-02-05Resident Rights DeficienciesGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.E – Moderate Harm Potential
2020-02-05Quality of Life and Care DeficienciesProvide activities to meet all resident's needs.E – Moderate Harm Potential
2020-02-05Nursing and Physician Services DeficienciesEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.E – Moderate Harm Potential
2020-02-05Quality of Life and Care DeficienciesProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.E – Moderate Harm Potential
2020-02-05Pharmacy Service DeficienciesEnsure medication error rates are not 5 percent or greater.E – Moderate Harm Potential
2020-02-05Infection Control DeficienciesProvide and implement an infection prevention and control program.E – Moderate Harm Potential
2020-02-05Resident Rights DeficienciesHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.D – Moderate Harm Potential
2020-02-05Quality of Life and Care DeficienciesProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.D – Moderate Harm Potential
2020-02-05Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2020-02-05Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2020-02-05Pharmacy Service DeficienciesImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.D – Moderate Harm Potential
2019-02-07Nursing and Physician Services DeficienciesEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.F – Moderate Harm Potential
2019-02-07Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2019-02-07Administration DeficienciesConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.F – Moderate Harm Potential
2019-02-07Nutrition and Dietary DeficienciesProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.E – Moderate Harm Potential
2019-02-07Resident Rights DeficienciesHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.D – Moderate Harm Potential
2019-02-07Quality of Life and Care DeficienciesProvide care and assistance to perform activities of daily living for any resident who is unable.D – Moderate Harm Potential
2019-02-07Quality of Life and Care DeficienciesProvide activities to meet all resident's needs.D – Moderate Harm Potential
2019-02-07Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential

Fire Safety Citation History

2 fire safety citations on record

DateCategoryDescriptionSeverity
2024-06-05Emergency Preparedness DeficienciesEstablish methods for sharing information.F – Moderate Harm Potential
2020-02-05Emergency Preparedness DeficienciesEstablish policies and procedures for volunteers.F – Moderate Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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