Trinity Care Center

In the surveyor’s words

From the most serious findings on record at Trinity Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 18, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF726Jul 18, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Oct 31, 2024

  Based 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 [DATE], [DATE], and [DATE]. 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 [DATE], [DATE], and [DATE]. 3. The facility failed to dispose of expired foods items located in the walk-in refrigerator. 4. […]

• No harm, potential for more than minimal, patternF584Jan 23, 2026

  Based 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. Findings included:During an observation on 01/20/2026 at 9:25 AM revealed tattered floors, walls and stains in the carpets of the hallways on 200 hall and 500 hall. […]

• No harm, potential for more than minimal, patternF677Jan 23, 2026

  Based 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.Findings included: 1. […]