Trinity Grove

Inspectors wroteBased on record review, observation, and staff, Power of Attorney, and Nurse Practitioner interview, the facility failed to protect a severely cognitively impaired resident (Resident #65) from the right to be free of physical abuse. On 08/29/25 at approximately 10:30 PM, when Nurse Aide (NA) #1 and NA #2 were providing care for Resident #65 who was agitated and combative, NA #2 struck the resident with an open hand on the left side of her face. This action would have caused a reasonable person psychosocial harm such as feelings of anger, fearfulness, humiliation, and helplessness. The deficient practice occurred for 1 of 3 residents reviewed for abuse (Resident #65).

Inspectors wroteBased on record review and staff and resident interviews, the facility failed to act upon concerns that were reported by the Resident Council and communicate the efforts to address concerns that were reported during Resident Council Meetings for 7 of 9 months reviewed (November 2024, March 2025, April 2025, May 2025, June 2025, July 2025 and August 2025).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to 1.) maintain clean technique (a strategy used during wound care to prevent or reduce the risk of transmission of microorganisms from one person to another or from one surface to another. This includes in part; maintaining a clean field (clean workspace) to prevent cross contamination) during wound care to a Stage III left heel pressure wound. Nurse #6 did not clean the work surface area or place a barrier prior to placing the wound care supplies that included a clean dressing onto the resident's dresser and did not place a barrier underneath the resident's (Resident #11) left heel during wound care which allowed the left heel to touch the floor and potentially contaminate the wound. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to document accurate information on the daily nurse staffing sheets to include the census for 4 of 4 days of the survey (09/15/25, 09/16/25, 09/17/25, and 09/18/25).

Inspectors wroteBased on record review, and Responsible Party (RP) and staff interviews, the facility failed to provide written grievance summaries for 1 of 1 resident (Resident #37).

Inspectors wroteBased on record review, and staff and the Medical Director's interviews, the facility failed to protect a resident's right to be free from physical abuse. On 5/18/24 a severely cognitively impaired resident (Resident #34) was grabbed around the neck using both hands and choked by another cognitively impaired resident (Resident #61) in the dining area of the locked dementia unit. Staff reported Resident #34 was crying and seemed distraught immediately following the incident. A second resident to resident altercation occurred on 5/25/24, 7 days later, when Resident #61 grabbed another cognitively impaired resident (Resident #17) by her neck with one hand and pushed her to the floor. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to implement their abuse policy for reporting an alleged violation of abuse when the facility failed to report two resident to resident altercations to the State Agency, Adult Protective Services, and to Law Enforcement following the altercations. There was no documentation that a written investigation was conducted. This occurred with 3 of 3 residents (Resident #34, Resident #61, and Resident #17) who were investigated for abuse.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to provide adaptive equipment for eating for 1 of 1 resident (Resident #62) reviewed for adaptive devices for eating.

Inspectors wroteBased on record review and staff interviews the facility failed to protect residents' right to be free from physical abuse perpetrated by Nurse Aide (NA) #2. On the evening of [DATE], NA #1 heard a slapping sound when 3 nurse aides were providing care. NA #1 turned around and asked NA #2 what happened. NA #2 stated she popped Resident #3 on the nose. During the day shift while two aides were providing care on [DATE], NA #1 observed NA #2 slap Resident #4 on the face. Resident #4 put her hand to her cheek and had a look of disbelief and shock after she was slapped. During the day shift, 15 minutes later, on [DATE] while two nurse aides were providing care, NA #3 observed NA #2 pop Resident #6 in the mouth two times. Due to the physical abuse a reasonable person would have experienced intimidation and fear. This was for 3 of 4 residents (Resident #3, #4 and #6) reviewed for abuse.

Inspectors wroteBased on record review and staff interviews the facility failed to identify and report abuse on [DATE] in the Alzheimer's unit when NA #1 heard a slapping sound while NA #1, NA #2, and NA #4 were providing care to Resident #3. NA #1 heard a slapping sound and turned around and asked NA #2 what happened. NA #2 stated she popped Resident #3 on the nose. NA #1 stated she did not know if what she witnessed was actual abuse and did not report it to Nurse #1 until [DATE]. The facility failed to protect other residents from physical abuse perpetrated by Nurse Aide (NA) #2 on [DATE] when NA #1 and NA #3 failed to report physical abuse to the nurse on the evening of [DATE] for Resident #3 and not until 4:00 PM on [DATE] for Resident #4 and Resident #6. On [DATE], NA #1 and NA #2 were providing care for Resident #4 and NA #1 observed NA #2 slap Resident #4 on the face. [...]

Inspectors wroteBased on record review, staff, Nurse Practitioner, and the Medical Director's interviews the facility failed to complete neurological assessments for a resident who experienced an unwitnessed fall and received an anticoagulant medication. This occurred for 1 of 3 residents (Resident #1) reviewed for falls.

Inspectors wroteBased on observation, staff and Director of Nursing interviews, and record review, the facility failed to: store an opened bottle of lorazepam in the locked drawer of the medication cart, label a bottle of ophthalmic solution and a bottle of eye drops with an opened date and discard 2 bottles of eye drops that had exceeded the manufacturer's recommendation for usage for 1 of 2 medication carts observed for medication storage.

Inspectors wroteBased on observations and staff interviews the facility failed to: keep an oscillating fan clean which was blowing onto the food preparation area of the kitchen.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to maintain dignity for a resident (Resident #76) with an uncovered urinary drainage bag, with urine visible for public view from the hallway. The reasonable person concept was applied as individuals have the expectation of being treated with dignity and would not want their urine visible to visitors, staff, and other residents, for 1 of 1 resident reviewed for dignity.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to adhere to the list of residents who met the criteria to have paid feeding assistants assist them with eating. Paid Feeding Assistant #1 was observed feeding Resident #68. Resident #68 was assessed to have difficulty swallowing and on a pureed diet and was not to be fed by a paid feeding assistant. The deficient practice occurred for 1 of 1 paid feeding assistant.