Trinity Care Center

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 (Resident #16, Resident #17, and Resident # 26) of 20 residents reviewed for resident rights. The facility failed to ensure Resident #16, Resident #17, and Resident #26's bedrooms had no scratches or holes on the walls next to their beds. The facility failed to ensure that the walls and carpets in 2 of 3 (200 hall, 400 hall) hallways were in good condition. These failures could place residents at risk of decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 of ten residents (Resident #32, Resident #100, and Resident #113) reviewed for ADLs. The facility failed to ensure Resident #113's fingernails were trimmed and clean. The facility failed to ensure Resident #32's and Resident #100's facial hair was shaved. These failures could place residents at risk of not receiving care services, diminished quality of life, and decreased self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish a system of accurate reconciliation and determine that drug records were in order, and that an account of all controlled drugs were maintained and periodically reconciled for 3 of 6 medication carts ( RN G's Medication Cart #1, RN H's medication cart #2, and RN I's Medication Cart #3) in the facility effecting 3 residents (Resident #5, Resident #55, and Resident #148) reviewed for pharmacy services.1. The facility failed to ensure RN G accurately reconciled Resident #5's narcotic medication log when she administered but did not sign for Resident #5's Lorazepam (controlled medication used for anxiety) 1 tablet and Acetaminophen/APAP (controlled medication used for pain) 1 tablets on 01/22/2026 at 8:48 a.m.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. There were 15 errors in 43 opportunities resulting in a 34.88% error rate, which involved 3 of 5 residents (Resident #70, Resident #109, and Resident #114) and 2 of 3 staff (MA C and MA D) observed during medication administration reviewed for medication errors. MA D failed to administer Spironolactone 25 mg (treating high blood pressure) ordered by physician for Resident #70. MA C failed to administer Namenda 5 mg (treating moderate to severe dementia) as ordered by physician for Resident # 114. MA C administered Resident #109's 13 medications outside of the allotted time frame. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure sanitation practices including cleaning the ice machine, cleaning the juice dispenser nozzle, cleaning the front of the convection oven, and cleaning the dish rack storage cart.2. The facility failed to label and date all food items in the kitchen.3. The facility failed to properly cover all food items to prevent contamination. These failures could place residents at risk of foodborne illness. Findings Included: During an observation on 1/20/26 at 9:22 a.m., revealed a container of spaghetti meat sauce and a container of winter vegetable blend on stovetop griddle uncovered. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 9 of 15 residents (Resident #18 and 8 residents in the dining room near nursing station C) reviewed for infection control.1. CNA E did not change gloves between dirty and clean peri-care tasks and did not sanitize her hands between glove changes during peri-care for Resident #18.2. CNA F and RN G did not sanitize their hands between passing meal trays for 8 residents in the dining room near nursing station C. These failures could place the residents at risk of infection transmission, sepsis, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident has the right to secure and confidential personal and medical records for 1 of 15 residents (Resident #87) reviewed for Privacy and Confidentiality. The facility failed to ensure Resident #87's clinical records were protected from being viewed by unauthorized persons when LVN J left Resident #87's personal information visible on the computer's screen on unattended medication cart. This failure could place residents' personal information at risk of being exposed to unauthorized individuals.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents had the right to be free of misappropriation of resident property and exploitation for 1 of 2 residents (Resident #1) reviewed for misappropriation and exploitation. The facility did not prevent misappropriation when on 11/04/2025 CNA A accessed Resident #1's personal cell phone and used Resident # 1's mobile cash application to transfer amounts of $ 31.00 and $50.00 to herself. This failure could place residents at risk of misappropriation of money, possessions, and feelings of loss. Record review of the facility provider investigation report written by the facility ADM, dated 11/05/2025, reflected: Resident #1 was a [AGE] year-old woman who resided at the facility for Rehabilitation care services. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 18 residents (Resident#1, Resident #3, and Resident #4) reviewed for dignity. The facility failed to ensure catheter bag was covered and not visible Resident#1, Resident #3, and Resident #4. This failure placed residents at risk of embarrassment and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for three (Resident #1, Resident #2, and Resident #17) of 18 residents reviewed for resident call system in that: The facility failed to ensure call lights were within reach for Resident #1, Resident#2, and Resident #17. This failure could have placed residents at risk of being unable to obtain assistance when needed

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure maintain medical records on each resident that are- Complete and accurately documented, for 3 (Resident #1, Resident #9, and Resident #10) of 5 residents reviewed for assessments in that: -The facility did not ensure Resident #1, Resident #9, and Resident #10's wound assessments accurately reflected current wound locations, measurements, or wound typeThis failure could place residents needing wound care at risk of not receiving proper care, treatments, and interventions.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 16 (Resident #1 and Resident #2) residents reviewed for accommodation of needs. 1. The facility failed to provide a working communication system, which was easily at reach at the bedside, which would allow Resident #1 to call for assistance. From 06/10/25 until 06/18/25, Resident #1 did not have a working communication system in her room. 2. The facility failed to provide a working communication system for Resident #2 on 06/18/25 when her call light was broken. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to label and date all food items located in the reach-in refrigerator, walk-in refrigerator, and walk-in freezer on 10/29/2024, 10/30/2024, and 10/31/2024. 2. The facility failed to effectively reseal all food items in the walk-in refrigerator and walk-in freezer to prevent contamination or spoilage on 10/29/2024, 10/30/2024, and 10/31/2024. 3. The facility failed to dispose of expired foods items located in the walk-in refrigerator. 4. The facility failed to clean the ice machines properly resulting in the presence of slime and an unidentified black substance build up in the ice machines on 10/29/2024 and 10/30/2024. 5. [...]

Inspectors wroteBased on interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 1 resident (Resident #102) reviewed for care plans. The facility failed to ensure Resident #102 had a care plan that reflected her new 7/8/24 diagnosis of unspecified convulsions (seizures). This failure could cause the staff to miss needed safety measures on the resident and place the resident at risk of injury from seizures.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for one of one facility reviewed for environment in that: 1. The facility failed to properly maintain sanitary emergency eyewash station in the kitchen when the protective eyewash covers were not properly positioned, not capped when not in use, and had a roll of paper towels inside the basin. The facility failed to keep the area clear and accessible to kitchen staff when the area was cluttered and blocked with brooms, a dustpan, a meal cart with soiled meal trays, a trash can, box of gloves, and rolls of trash bags. These failures could place staff at risk for an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on interview, and record review the facility failed to develop and implement interventions the person-centered care plan to reflect the current condition for 1 (Residents # 1) of 5 residents reviewed for care plan interventions. The facility failed to update Resident # 1's care plan for diet interventions after her diet order was changed. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on interviews and record review, the facility failed to provide food that accommodates residents allergies, intolerances, and preferences for 1 (Resident # 1) of 5 residents reviewed for food preferences. The staff did not accommodate Resident # 1's dietary preferences for a vegetarian diet. This failure could affect the residents that are provided daily meals by the facility, by placing them at risk for adverse effect from food, frustration, not enjoying meals, and weight loss.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents had a right to be free from neglect for 1 (Resident #1) of 6 residents reviewed for neglect. The facility failed to ensure CNA A reported that she observed signs and symptoms of dizziness from Resident #1 before taking her to the shower room on [DATE]. CNA A did not report to anyone what she observed and continued to take Resident #1 to the shower room. While CNA A's back was turned in the shower room to grab something, Resident #1 got up from a shower bench unassisted, fell, and sustained a nondisplaced right inferior pubic ramus fracture and right parietal scalp hematoma with underlying acute traumatic subarachnoid hemorrhage. Resident #1 was sent to the ER and placed on hospice for comfort care. On [DATE], Resident #1 passed away. An IJ was identified on [DATE]. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental and psychosocial well-being for 1 (CNA A) of 9 CNAs reviewed for competent nursing care. The facility failed to ensure CNA A was proficient in reporting residents' change in condition and resident shower safety. CNA A did not report that she observed Resident #1 having s/s of dizziness and did not have all shower supplies prepared before taking Resident #1 to the shower room. CNA A took Resident #1 to the shower room, turned her back to grab something, Resident #1 got up from the shower bench unassisted and fell in the shower room. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Residents #1 and #2) of 6 reviewed for neglect and injuries of unknown origin. 1. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 6 of 22 residents (Resident #s 1, 2, 3, 4, 5 &6) reviewed for resident rights. The facility failed to treat Resident #s1, 2, 3, 4, 5 & 6 with respect and dignity when they did not receive their lunch meal tray while the other residents seated with them in the dining room were already eating. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of fifteen residents (Resident # 4, Resident #4, Resident #73, and Resident #109 ) reviewed for quality of life. The facility failed to ensure Resident#4's, Resident #52's, Resident #73's, and Resident #109's fingernails were trimmed and cleaned. These failures could place residents at risk for poor hygiene, dignity issues and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice for one (Resident #1) of eight residents reviewed for self-determination. CNA L denied Resident #1 the right to attend a group therapy activity. This failure placed Resident #1 at risk of mental anguish.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure each resident received adequate supervision and assistant devices to prevent accidents for 1 or 2 residents (Resident # 25) reviewed for accidents and hazards, in that: supervision. The facility failed to ensure staff properly transferred Resident #25 from her bed to wheelchair and suffered pain on her right arm between the elbow and the wrist. This failure could result in residents experiencing accidents, injuries, unrelieved pain, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to sign and date all orders for one (Resident #1) of eight residents reviewed for physician services. The facility's Physician failed to sign Resident #1's verbal order for hospice care. The facility failed to include in Resident #1's chart a signed order for hospice care. These failures placed Resident #1 at risk of receiving unconfirmed hospice services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7 % based on 2 errors out of 32 opportunities, which involved 2 of 6 residents (Resident #15, and Resident #274) reviewed for medication errors. - MA N failed to apply medications as ordered to Resident #15 as by applying Lidocaine 4% patch to the resident's right knee instead of the back. - Facility failed to store and administer medications as ordered to Resident #274 by not ordering Linaclotide 290 mcg PO mg ER (medication for constipation). These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled pain.