Provider Name: TRINITY WOODS, INC.
Address: 4134 EAST 31ST STREET, TULSA, OK 74135
Phone: (918) 743-2565
County: Tulsa (710)
Ownership Type: Non profit - Corporation
Certified Beds: 84
Average Residents Per Day: 61.9 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: TRINITY WOODS
First Approved Date: November 1, 2003
Affiliated Entity: ()
Retirement Community: Y, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 4 ()
Health Inspection Rating: 4 ()
QM Rating: 2 ()
Long Stay QM Rating: 1 ()
Short Stay QM Rating: 3 ()
Staffing Rating: 4 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 3.60649, LPN Staff Hours Per Day: 1.7351, RN Staff Hours Per Day: 0.4387, Licensed Staff Hours Per Day: 2.1738
Total Nurse Staff Hours Per Day, per resident: 5.78030
Weekend Nurse Staff Hours: 5.28558, Weekend RN Staff Hours: 0.2692
PT Staff Hours Per Day, per resident: 0.0571
Nurse Staff Turnover: 43.3, Nurse Turnover Note:
RN Turnover: , RN Turnover Note: 6
Admin Left Number: 0, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 2.1228, Case Mix LPN Hours Per Day: 0.6630, Case Mix RN Hours Per Day: 0.2991
Adjusted Nurse Aide Hours Per Day, per resident: 3.46111, Adjusted LPN Hours Per Day: 1.9313, Adjusted RN Hours Per Day: 0.5526
Total Adjusted Nurse Hours Per Day, per resident: 5.90601
Adjusted Weekend Nurse Hours Per Day, per resident: 5.40053
Health Survey Dates and Scores: Cycle 1: 2023-06-15 (Score: 8), Cycle 2: 2019-12-06 (Score: 32), Cycle 3: 2018-10-09 (Score: 88)
Total Weighted Health Score: 29.333
Reported Incidents: 0, Substantiated Complaints: 0
Infection Control Citations:
Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 650.00, Payment Denials Number: 0, Total Penalties Number: 1
Location and GPS: 4134 EAST 31ST STREET,TULSA,OK,74135 (36.1188, -95.930)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-17
Type: Health, Deficiency: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-02-06
Type: Health, Deficiency: Notify 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.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-02-06
Type: Health, Deficiency: Ensure each resident receives an accurate assessment.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-02-06
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-02-06
Type: Health, Deficiency: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-11-01
Type: Health, Deficiency: Assure that each resident’s assessment is updated at least once every 3 months.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-11-01
Type: Health, Deficiency: Ensure each resident receives an accurate assessment.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-11-01
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-11-01
Type: Health, Deficiency: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-11-01
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: H - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-11-01
Type: Health, Deficiency: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-11-01
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0761, Version: New
Description: To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-01-15
Type: Fire Safety, Tag: 0222, Version: New
Description: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-11-01