Brookdale Trinity Towers

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) reviewed for infection control practices. The facility failed to ensure Resident #1 had an EBP sign posted outside of his room due to having a Foley Catheter. The facility failed to ensure CNA-B wore the appropriate PPE when providing care to Resident #1. These failures could place residents at risk for cross-contamination and infection.

Inspectors wroteBased on Record reviews and interviews, the facility failed to ensure that one resident (Resident #2) of five residents discharged did not receive the required 30-day notice of discharge. The facility failed to ensure Resident #2 was given a 30-day discharge notice. Resident #2 was discharge on [DATE]. The failure could put residents at risk for inappropriate discharge from the facility and cause psychological harm due to feelings of anger and sadness. This failure could place discharged residents at risk of being discharged from the facility causing a disruption in their care and/or services

Inspectors wroteBased on record reviews and interviews, the facility failed to send a copy of the discharge notice, prior to the discharge, to the representative of the Office of State Long-Term Care Ombudsman for two residents (Resident #1 and Resident #2) of five residents reviewed for discharge. The facility failed to send a copy of Resident #1 and Resident #2's discharge notice, prior to discharge, to the representative of the Office of State Long-Term Care Ombudsman. These failures could have placed the residents at risk of not knowing their rights or receiving the services of the state Long Term-Care Ombudsman. Findings Included: Review of Resident #1 face sheet dated 06/04/26 revealed she was an [AGE] year-old female admitted on [DATE] with diagnosis of dysphagia (difficulty swallowing); [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 6 residents (Resident #1) reviewed for medical records. The facility failed to document the amount of food Resident #1 ate during her 3 meals per day for 10 times from March 1st through March 15th, 2026. This failure could place residents at risk of not receiving proper care or having needs met due to inappropriate documentation.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive assessment within 14 calendar days after admission as required for 1 (Resident#70) of 7 resident records reviewed for assessment. The facility failed to complete Resident #70's comprehensive MDS assessment within 14 days following her admission to the facility on [DATE]. This failure could place newly admitted residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident needs, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 7 residents (Resident #60) reviewed for care plans. The facility failed to ensure Resident #60's care plan reflected her ADLs with assistance needed. This failure could place the residents at risk of not receiving appropriate interventions and care to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to review and revise the comprehensive care plan by the interdisciplinary team, for 1 of 7 residents (Resident #7) reviewed for comprehensive care plan revisions. The facility failed to review and revise Resident #7's care plan to reflect she no longer used a catheter. This failure could place the residents at risk of not receiving appropriate interventions and care to meet their current needs.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure a resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, and maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or the resident preferences indicate otherwise for 1 (Resident #70) of 7 residents reviewed for nutritional status. The facility failed to ensure Resident #70 was weighed weekly for 3 weeks after admission per physician's orders. This failure could place residents at risk for nutritional deficit, weight loss, skin breakdown, and overall decline in quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident in 2 of 2 medication rooms (4th floor and 5th floor) reviewed for pharmacy services. The facility failed the ensure expired medication was removed from the 4th floor medication storage room. The facility failed the ensure expired medication was removed from the 5th floor medication storage room. These failures could place residents at risk of not receiving the therapeutic benefit of medications and or adverse reactions to medications.

Inspectors wroteBased on observation, interviews and record review, the facility failed to store food in accordance with professional standards for 1 of 1 freezer and 1 of 2 medication storage rooms (4th floor medication room) reviewed for food safety.-The facility failed to ensure food items (raw dinner rolls, breaded chicken tenders, and breaded fish) in the freezer were sealed properly.-The facility failed to ensure resident food items were disposed of according to policy. -The facility failed to ensure the resident food and drink refrigerator in a medication storage room was clean and did not have any food or drink remnants in it. These failures could place residents at risk of complications from food contamination.

Inspectors wroteBased on observation and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure infusion therapy supplies were stored under sterile conditions in the 4th floor medication storage room. The facility failed to ensure used oxygen equipment was not stored in the 4th floor medication storage room. These failures could place residents at risk of cross contamination and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan was developed and implemented within a timely manner for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 1 (Resident #1) out of 5 residents reviewed for care plans. The facility failed to add the fall with significant injury, fall mats, and the surgical wound with wound care to Resident #1's care plan. The facility also failed to complete Resident #1's comprehensive care plan within the specified time frame. These failures could place residents at risk for receiving inadequate care and services.

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (K2) reviewed and 2 of 2 satellite kitchens (SK4 and SK2) for storage, preparation, and sanitation. 1. Satellite Kitchen 4 (SK4) The facility failed to maintain cleanliness of the steam table holding wells and shelf, that a cleaning schedule was followed, personal items were not kept in the dry storage room, and all staff wore a hair and beard net while in SK4. 2. Satellite Kitchen 2 (SK2) The facility failed to maintain cleanliness of the steam table holding wells and shelf, that a cleaning schedule was followed, and personal items were not kept in the server room, in SK2. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 3 of 12 residents (Residents #15, #33, and #152) observed for infection control practices. The facility failed to post Enhanced Barrier Precaution signs outside the rooms of Resident #'s 15, 33 and 152. These failures could place residents, staff, and visitors at risk of cross contamination and/or infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all kitchen equipment in safe operating condition for 1 of 1 kitchen (K2) reviewed and 1 of 2 satellite kitchens (SK2) reviewed for safe operating equipment. The facility failed to maintain a chest type freezer with heavy ice build-up on the inside walls, bottom, and lid in SK2. The facility failed to maintain and remove a 4-foot X 3-foot char broiler that did not work, had no griddle on it, and was connected to the gas line in K2. The facility failed to maintain and remove dented holding pans and dented prep equipment (food mill) in K2. The facility failed to maintain the walk-in freezer by not allowing ice accumulation around the fan and low lighting in K2. These failures could cause food-borne illness from equipment not being maintained and/or cleaned effectively.

Inspectors wroteBased on interviews, observations and record review, the facility failed to develop a comprehensive person-centered care plan based on assessed needs that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #15 and Resident #30) of 16 residents reviewed for comprehensive person-centered care plans. The facility failed to develop and implement Resident #15's care plan to include oxygen therapy. The facility failed to develop and implement Resident #30's care plan to include oxygen therapy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for one of one resident (Resident #198) reviewed for tracheostomy care . 1. The facility failed to ensure Resident #198 had suction equipment, emergency supplies, a spare trach or a care plan specific for tracheostomy care. 2. The facility failed to ensure staff could describe steps to take in the event of an emergency dislodgement of Resident #198's trach. 3. The facility failed to ensure staff were competent in trach care and knowledgeable of equipment needed. These failures could place residents at risk for suffocation and death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for two residents (R #159 and R #200) reviewed for restorative care. The facility failed to apply knee immobilizer to Resident #159's knee to reduce the risk of further loss of range of motion. The facility failed to back immobilizer to Resident #200's back to reduce the risk of further loss of range of motion. This failure placed residents on restorative nursing care at risk for decline in range of motion, and decreased mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for of two of five medication carts (200 and 300 Hall 2nd floor Medication Cart) reviewed for medication storage The facility failed to ensure, 200 and 300 hall medication carts were locked when unattended. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food plates. 1. Upon two separate visits to the 4th floor satellite kitchen revealed a worn, distressed looking temperature log binder being placed to lean against the food plates that are served to the residents for their meals every day. This failure could place residents at risk for cross-contamination and food-borne illnesses. 2. The facility failed to ensure staff did not store their personal drinks in the preparation area of the facility kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for one of 30 residents (Resident #200) reviewed for comprehensive assessments. The facility failed to complete an accurate updated comprehensive assessment for Resident #200. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives, and timeframes to meet a residents medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two of two residents (Resident #198 and Resident #200) reviewed for care plans. 1. The facility failed to develop a care plan to address Resident #198's tracheotomy care needs or address emergency management in the event of a dislodgement. 2. The facility failed to correctly assess/identify/document Resident #200's current physical functioning and the use of a back brace in his initial assessment dated [DATE]. These failures could place resident's at risks of suffocation or death.

Inspectors wroteBased on observation, interview and record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for Resident #160 of 55 residents reviewed for infection control. 1. LVN C did not perform hand hygiene for 20 seconds or greater while performing wound care on Resident #160. These failures could place residents at risk for infection through cross contamination of pathogens.

Inspectors wroteBased on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one resident (Resident -R# 1) of five residents that were reviewed for infection control and transmission-based precautions policies and practices, in that: The facility failed to ensure LVN A performed hand hygiene and removed her contaminated gloves prior to the commencement of perineal care after she touched multiple surfaces. This failure could place residents at risk for infection through cross contamination of pathogens.