Pine Bluff, AR

Trinity Village Medical Center

3-star overall rating with 3-star inspections with 4 recent health deficiencies

6400 Trinity Drive, Pine Bluff, AR

(870) 879-3117

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2010-12-17

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.29

Registered nurse staffing · state 0.40 · national 0.68

LPN hours / resident day

1.22

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.67

Nurse aide staffing · state 2.72 · national 2.35

Total nurse hours

4.18

All reported nurse hours · state 4.07 · national 3.89

Licensed hours

1.51

RN + LPN hours · state 1.35 · national 1.54

Weekend hours

3.71

Weekend nurse staffing · state 3.48 · national 3.43

Weekend RN hours

0.26

Weekend registered nurse coverage · state 0.27 · national 0.47

Physical therapist

0.11

Reported PT staffing · state 0.03 · national 0.07

Adjusted RN hours

0.31

CMS adjusted RN staffing hours

Adjusted total hours

4.51

CMS adjusted total nurse staffing hours

Case-mix index

1.27

Higher values indicate more complex resident acuity

RN turnover

67%

Annual RN turnover · state 48% · national 45%

Total nurse turnover

42%

Annual nurse turnover · state 51% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,513

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

43.97

Composite VBP score used to determine payment impact.

Payment multiplier

0.9970

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.35

Baseline 23.04% · Performance 21.93% · Measure score 1.35 · Achievement 0 · Improvement 1.35

Healthcare-associated infections

3.23

Baseline 6.63% · Performance 6.87% · Measure score 3.23 · Achievement 3.23 · Improvement 0

Total nurse turnover

6.53

Baseline 38.89% · Performance 37.00% · Measure score 6.53 · Achievement 6.53 · Improvement 0.85

Adjusted total nurse staffing

6.48

Baseline 5.30 hours · Performance 4.92 hours · Measure score 6.48 · Achievement 6.48 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.45%	10.72% 0.7 pts worse	No Different than the National Rate · Eligible stays 94 · Observed rate 13.83% · Lower 95% interval 7.63%
Discharge to community	26.08%	50.57% 24.5 pts worse	Worse than the National Rate · Eligible stays 61 · Observed rate 14.75% · Lower 95% interval 18.74%
Medicare spending per beneficiary	1.06	1.02 About the same
Drug regimen review with follow-up	87.65%	95.27% 7.6 pts worse	Numerator 71 · Denominator 81
Falls with major injury	1.23%	0.77% 0.5 pts worse	Numerator 1 · Denominator 81
Discharge self-care score	60%	53.69% 6.3 pts better	Numerator 30 · Denominator 50
Discharge mobility score	46%	50.94% 4.9 pts worse	Numerator 23 · Denominator 50
Pressure ulcers or injuries, new or worsened	8.64%	2.29% 6.4 pts worse	Numerator 7 · Denominator 81 · Adjusted rate 7.96%
Healthcare-associated infections requiring hospitalization	6.87%	7.12% 0.2 pts better	No Different than the National Rate · Eligible stays 69 · Observed rate 5.8% · Lower 95% interval 3.89%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 196
Staff flu vaccination coverage	63.07%	42% 21.1 pts better	Numerator 111 · Denominator 176
Discharge function score	52%	56.45% 4.5 pts worse	Numerator 26 · Denominator 50
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 25 · Denominator 25
Transfer of health information to patient	96.43%	96.28% 0.2 pts better	Numerator 27 · Denominator 28
Resident COVID-19 vaccinations up to date	0%	25.2% 25.2 pts worse	Numerator 0 · Denominator 53

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.9	2.0 0.9 pts worse	1.9 1 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.3 · Expected 1.5 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	4.2	2.2 2 pts worse	1.8 2.4 pts worse	Long Stay · 20240701-20250630 · Adjusted 4.2 · Observed 3.6 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	69.2%	94.9% 25.7 pts worse	93.4% 24.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 62.7% · Q2 64.9% · Q3 76.7% · Q4 72.9% · 4Q avg 69.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.7%	96.1% 2.6 pts better	95.5% 3.2 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7%
Percentage of long-stay residents experiencing one or more falls with major injury	3.1%	3.9% 0.8 pts better	3.3% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.7% · Q3 2.7% · Q4 4.3% · 4Q avg 3.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	1.4% 1.4 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	9.4%	4.9% 4.5 pts worse	5.4% 4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 9.8% · Q3 10.0% · Q4 5.1% · 4Q avg 9.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	13.1%	21.8% 8.7 pts better	19.6% 6.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 14.3% · Q3 11.1% · Q4 15.0% · 4Q avg 13.1%
Percentage of long-stay residents who received an antipsychotic medication	4.0%	12.5% 8.5 pts better	16.7% 12.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 7.4% · Q3 2.0% · Q4 1.9% · 4Q avg 4.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	20.1%	11.4% 8.7 pts worse	16.3% 3.8 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 20.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	6.9%	10.4% 3.5 pts better	14.9% 8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 10.0% · Q3 6.0% · Q4 6.1% · 4Q avg 6.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.5%	0.7% 0.8 pts worse	1.0% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.3% · Q3 0.9% · Q4 1.1% · 4Q avg 1.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	3.2%	1.1% 2.1 pts worse	1.7% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 2.9% · Q4 7.2% · 4Q avg 3.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	17.0%	14.6% 2.4 pts worse	19.8% 2.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 28.5% · Q3 14.6% · Q4 13.3% · 4Q avg 17.0%
Percentage of long-stay residents with pressure ulcers	5.8%	4.6% 1.2 pts worse	5.1% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 6.1% · Q3 6.1% · Q4 3.5% · 4Q avg 5.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	22.2%	81.8% 59.6 pts worse	81.7% 59.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 19.3% · Q3 30.2% · Q4 25.5% · 4Q avg 22.2%
Percentage of short-stay residents who had an outpatient emergency department visit	22.4%	13.8% 8.6 pts worse	12.0% 10.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 23.5% · Expected 11.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.7%	1.4% 0.7 pts better	1.6% 0.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 0.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	87.7%	77.9% 9.8 pts better	79.7% 8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 87.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	30.3%	25.2% 5.1 pts worse	23.9% 6.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 30.3% · Observed 33.3% · Expected 26.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-24 · Fire 2025-07-24

4 health deficiencies

Top issue: Infection Control (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2025-01-16 · Fire 2025-01-16

12 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2024-07-18 · Fire 2024-07-18

15 health deficiencies

Top issue: Nutrition and Dietary (4 deficiencies)

3 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-01-16

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2025-02-17

F · Potential for more than minimal harm 2025-01-16

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2025-02-17

F · Potential for more than minimal harm 2025-01-16

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-02-17

F · Potential for more than minimal harm 2024-07-18

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2024-08-16

F · Potential for more than minimal harm 2024-07-18

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-08-16

F · Potential for more than minimal harm 2024-07-18

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-08-16

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-07-24

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-08-15

E · Potential for more than minimal harm 2025-07-24

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-08-15

D · Potential for more than minimal harm 2025-07-24

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-08-15

D · Potential for more than minimal harm 2025-07-24

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-08-15

E · Potential for more than minimal harm 2025-01-16

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2025-02-17

E · Potential for more than minimal harm 2025-01-16

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2025-02-17

E · Potential for more than minimal harm 2025-01-16

F700 · Quality of Life and Care Deficiencies

Health

Try 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.

Corrected 2025-02-17

E · Potential for more than minimal harm 2025-01-16

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-02-17

E · Potential for more than minimal harm 2025-01-16

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-02-17

E · Potential for more than minimal harm 2025-01-16

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-02-17

E · Potential for more than minimal harm 2025-01-16

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2025-02-17

E · Potential for more than minimal harm 2025-01-16

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-02-17

E · Potential for more than minimal harm 2025-01-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-02-17

D · Potential for more than minimal harm 2025-01-16

F688 · Quality of Life and Care Deficiencies

Health

Provide 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.

Corrected 2025-02-17

D · Potential for more than minimal harm 2025-01-16

F758 · Pharmacy Service Deficiencies

Health

Implement 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.

Corrected 2025-02-17

D · Potential for more than minimal harm 2025-01-16

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2025-02-17

F · Potential for more than minimal harm 2024-07-18

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-08-16

E · Potential for more than minimal harm 2024-07-18

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-08-16

E · Potential for more than minimal harm 2024-07-18

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-08-16

E · Potential for more than minimal harm 2024-07-18

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-08-16

E · Potential for more than minimal harm 2024-07-18

F726 · Nursing and Physician Services Deficiencies

Health

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.

Corrected 2024-08-16

E · Potential for more than minimal harm 2024-07-18

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2024-08-16

E · Potential for more than minimal harm 2024-07-18

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-08-16

E · Potential for more than minimal harm 2024-07-18

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2024-08-16

E · Potential for more than minimal harm 2024-07-18

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2024-08-16

E · Potential for more than minimal harm 2024-07-18

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2024-08-16

E · Potential for more than minimal harm 2024-07-18

F847 · Administration Deficiencies

Health

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Corrected 2024-08-16

E · Potential for more than minimal harm 2024-07-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-08-16

D · Potential for more than minimal harm 2024-07-18

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-08-16

D · Potential for more than minimal harm 2024-07-18

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-08-16

D · Potential for more than minimal harm 2024-07-18

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-08-16

Penalties and ownership