Trinity Homes

Inspectors wroteBased on record review, review of the facility reported incident (FRI) and investigation, review of competency/verification/training documents, and staff interview, the facility failed to provide supervision and assistance devices to prevent an accident for 1 of 1 sampled resident (Resident #1) injured during a facility van transport. Failure to secure the shoulder strap on the resident during transport resulted in Resident #1 sustaining a leg fracture. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident.

Inspectors wrote1. Based on observation, record review, and resident and staff interviews, the facility failed to properly utilize assistive devices necessary to prevent accidents for 1 of 5 residents (Resident #29) observed for transfers. Failure to utilize a gait belt during transfers placed the resident at risk of injury.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 3 of 11 sampled residents (Resident #12, #29 and #59) and 1 supplemental resident (Resident #126) observed for cares and/or medication administration. Failure to practice infection control standards related to enhanced barrier precautions (EBP), glove use, hand hygiene, and disinfecting of shared equipment has the potential to spread infection throughout the facility.

Inspectors wroteBased on record review, review of facility policy, and resident, resident representative, and staff interviews, the facility failed to ensure the right to participate in the development and implementation of a person-centered plan of care for 2 of 31 sampled residents (Resident #6 and #118). Failure to ensure residents or their representative received notice of care planning conferences and/or interviewed the resident or their representative regarding care concerns/needs if they chose not to attend the conferences, limited their right to make decisions/provide input related to the resident's care, treatment, and services.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment for 1 of 31 sampled residents (Resident #84) reviewed for advance directives. Failure to ensure the resident's medical record reflected the most current resident wishes may result in unwanted treatment.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure all alleged violations involving possible abuse/neglect were reported immediately to officials including the State Survey Agency (SSA) for 1 of 1 sampled resident (Resident #1) who eloped from the facility. Failure to immediately report alleged violations to the SSA placed Resident #1 and other residents at risk for possible neglect and/or injury. Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 08/14/25. This policy, revised August 2023, stated, . Neglect: Means the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress . The Director of Nursing and/or Director of Social Services will report the alleged . neglect . [...]

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to thoroughly investigate alleged violations of neglect for 1 of 1 sampled resident (Resident #1) who eloped from the facility. Failure to thoroughly investigate Resident #1's elopement, implement corrective actions, and evaluate the effectiveness of those actions, placed Resident #1 and other residents at risk for possible neglect and/or injury. Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 08/14/25. This policy, revised August 2023, stated, . Neglect: Means the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress . [...]

Inspectors wroteBased on record review, review of professional reference, review of facility policy, and staff interview, the facility failed to follow professional standards of practice regarding physician's orders for 1 of 1 sampled resident (Resident #30) with orders for a physical therapy/occupational therapy (PT/OT) evaluation. Failure to transcribe and obtain a PT/OT evaluation placed Resident #30 at risk for delayed treatment.

Inspectors wroteBased on observation, record review, and resident and staff interview, the facility failed to ensure residents received the necessary services to maintain personal hygiene for 2 of 23 sampled residents (Resident #4 and #104) dependent on staff for personal hygiene. Failure to provide assistance with hair, oral, and nail care may result in poor hygiene and decreased self-esteem and quality of life.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services for 1 of 6 sampled resident (Resident #6) observed during dressing changes. Failure to complete dressing changes as physician ordered placed the resident at risk for delayed wound healing.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary treatment/services to prevent skin breakdown and pressure ulcers for 1 of 4 sampled residents (Resident #4) reviewed with pressure ulcers. Failure to consistently reposition residents for pressure relief may result in delayed healing of current pressure ulcers and/or the development of new pressure ulcers.

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to provide appropriate services and assistance to maintain bowel continence for 1 of 2 sampled residents (Resident #4) observed during toileting/incontinence cares. Failure to provide alternate toileting methods may result in unnecessary incontinence, a loss of dignity, and avoidable skin issues.

Inspectors wroteBased on observation, record review, review of facility policy, and staff, resident, and family interviews the facility failed to offer and/or assist with fluids for 3 of 8 residents (Resident #2, #13, and #14) who required staff assistance for fluid intake. Failure to provide fluids to dependent residents may result in dehydration, constipation, and urinary tract infections.

Inspectors wroteBased on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 9 residents (Resident #65 and #96) observed during medication administration. Two medication errors occurred during staff administration of 27 medications, resulting in a 7% error rate. Failure to follow physicians' orders and administer medications in the correct dose and at the correct time may result in residents receiving an ineffective and/or inaccurate dose and experiencing adverse reactions.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure accurate medication labeling for 1 of 8 residents (Resident #12) observed during medication administration and failed to discard expired medications in 3 of 7 medication storage areas (3 North East cart and cupboard and 3 South refrigerator) reviewed. Failure to ensure medication labels reflect the current physician orders may result in inaccurate dosages and failure to discard expired medications may result in decreased effectiveness of the prescribed medication.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to discard expired food and supplements in 2 of 6 food storage areas (Main kitchen and 4 North kitchenette) observed. Failure to discard expired food/supplements has the potential to affect the quality of the item served to residents related to safety and nutrition.

Inspectors wroteBased on observation, record review, review of a facility reported incident, policy review, and staff interview, the facility failed to ensure residents remained free from abuse for 2 of 2 sampled residents (Resident #1 and #2) with impaired cognition who displayed sexual behaviors towards each other. Failure to protect residents from sexual abuse may result in fear, anxiety, mental anguish, and physical injury. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident.

Inspectors wroteBased on record review, review of the facility reported incident, review of facility policy, and staff interviews, the facility failed to ensure residents remained free from abuse from 1 of 1 sampled resident (Resident #1) with verbal, physical, and sexual behaviors towards other residents. Failure to assess, care plan, and operationalize a plan/process resulted in fear, anxiety, pain, and an unsafe environment for all residents residing in the memory care unit.

Inspectors wroteBased on record review, review of facility policy, and staff interviews, the facility failed to provide adequate dementia care and services for 1 of 1 sampled resident (Resident #1) with dementia and verbal, physical, and sexual abusive behaviors. Failure to adequately assess for necessary care and services and implement effective behavior management interventions resulted in a decreased level of psychosocial well-being for Resident #1 and had a negative impact on other residents.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide appropriate treatment and services to prevent the development of a pressure ulcer for 1 of 5 sampled residents (Resident #68) with pressure ulcers. Failure to implement interventions as ordered, and ensure adequate monitoring/assessment resulted in an avoidable facility acquired pressure ulcer.

Inspectors wrote2. Based on observation, record review, review of facility policy, review of manufacturer's instructions, and staff interview, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 2 of 3 sampled residents (Resident #4) observed during a sit-to-stand lift transfer and (Resident #36) observed with bruises. Failure to use a mechanical lift properly and/or re-evaluate the suitability of a mechanical lift transfer, and monitor/ensure safe transfer methods placed Residents #4 and #36 at risk for injury.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 6 of 25 sampled residents (Residents #29, #33, #66, #68, #88, and #317). Failure to review and revise the care plan limited staff's ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on observation and staff interview, the facility failed to store food in a sanitary manner in 1 of 1 main kitchen. Failure to maintain freezing systems has the potential to affect food quality/preparation and may result in the spread of foodborne illness to residents, staff, and visitors.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 6 of 25 sampled residents (Resident #11, #41 #68, #69, #80, and #317) and one supplemental resident (Resident #60) observed during cares and one supplemental resident (Resident #43) with a foley catheter. Failure to practice infection control standards related to use of enhanced barrier precautions (EBP), personal protective equipment (PPE), and hand hygiene has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, record review, review of professional reference, and staff interview, the facility failed to provide care in accordance with professional standards for 2 of 2 sampled residents (Resident #29 and #41). Failure to obtain physician's orders and notify the physician of refusal of treatments may result in adverse health effects.

Inspectors wroteBased on observation, record review, review of professional reference, and staff interview, the facility failed to restore, if possible, oral eating skills for 1 of 1 sampled resident (Resident #33) with a gastrostomy tube (tube inserted into the stomach for feeding) and orders for oral intake. Failure to clarify orders and evaluate oral intake may have the potential to result in adverse events, such as aspiration pneumonia.

Inspectors wroteBased on observation, record review, review of professional reference, and staff interview, the facility failed to ensure appropriate infection control practices for 1 of 1 resident (Resident #54) receiving oxygen via a tracheostomy. Failure to maintain cleanliness of respiratory supplies by ensuring appropriate storage could result in adverse effects for the resident.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the resident's medication regimen remained free of unnecessary medications for 3 of 5 sampled residents (Resident #21, #66, and #68) reviewed for antipsychotic medications. Failure to establish a baseline by assessing for abnormal involuntary movements before starting an antipsychotic and to monitor periodically while on the medication may result in the resident experiencing adverse consequences related to the antipsychotic medication.

Inspectors wroteBased on review of State Survey Agency reports, record review, review of facility policy, and staff interview, the facility failed to report an incident of serious bodily injury for 1 of 1 sampled resident (Resident #1) who experienced serious injury after a fall from a lift to the State Survey Agency (SSA). Failure to report an event that resulted in serious bodily injury in the prescribed time frame does not comply with regulations established to protect residents.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for 1 of 1 sampled resident (Resident #1) who had a fall from a mechanical lift with facial laceration. Failure to document the fall assessment timely, ensure post-fall follow up is performed and documented. Failure to perform and document neurological assessments following a fall with facial laceration has the potential to delay identification and treatment of further or worsening signs/symptoms of injury.

Inspectors wroteBased on record review, review of facility investigation, and review of facility policy, the facility failed to ensure adequate supervision and assistance for 1 of 2 sampled residents (Resident #68) who required staff assistance with transfers and experienced a fall with fracture injury.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure acceptable parameters of nutritional status for 1 of 1 sampled resident (Resident #315) with documented weight variances indicating severe weight loss. Failure to reassess weight variances may delay needed treatment for weight loss/gain and alter the resident's ability to maintain a sufficient health/nutritional status.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to ensure a medication error rate of less than five percent during administration of medications for 1 of 7 residents (Resident #315) observed. Four medication errors occurred during staff administration of 32 medications, resulting in a 12% error rate. Failure to properly prepare and administer medications may result in residents receiving an ineffective dose and experiencing adverse reactions.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure safe and secure storage of medications for 1 of 4 medication carts (4 East wing) observed during medication pass. Failure to store all medications securely may result in unauthorized access to medications.