Trinity Community

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 10, 2023

  Based on medical record review, observations, staff interviews, resident representative interview, community member interviews, review of the facilities investigations, review of hospital records, review of witness statements, review of online resources from Weather Underground (online resources for weather conditions), and review of the facility's policy regarding elopement, the facility failed to provide adequate supervision for Resident #82, who had severely impaired cognition, a history of dementia, increased confusion, poor judgment and displayed exit seeking behaviors. […]

• Actual harm, isolatedF684Apr 18, 2024

  Based on staff interview, record review, facility protocol review, and hospital record review, the facility failed to ensure residents received treatment and care in accordance with professional standards when they failed to hold blood pressure medications and notify the doctor of a low blood pressure for Resident #77. This resulted in actual harm when Resident #77 was hospitalized for nine days with hospital diagnoses of hypotension, acute kidney injury, and altered mental status. Resident #77 had an elevated Blood Urea Nitrogen (BUN) level of 110 milligrams per deciliter (mg/dl), and elevated creatinine level of 3.22 mg/dl, and a hospital emergency room triage blood pressure of 80/36 millimeters of mercury (mmHg). […]

• No harm, potential for more than minimal, widespreadF812Apr 3, 2025

  Based on observation, staff interview, and policy review, the facility failed to store, prepare, distribute, and serve foods in accordance with professional standards for food service safety. This had the potential to affect 79 residents in the facility. The facility identified two residents (21 and #137) who did not receive food from the kitchen. The facility census was 81. Findings include: Observation of the kitchen's reach in coolers on 03/31/25 at 8:25 A.M. revealed the following: a. a plastic tub of yogurt, opened and partially used, with no open date b. a bag of spinach with an open date of 03/20 c. two packages of lunch meat, opened and not dated d. a bag of hotdogs, opened, not sealed, not dated e. a plastic container of cheese slices, not labeled, not dated f. […]

• No harm, potential for more than minimal, widespreadF814Apr 3, 2025

  Based on observation and staff interview, the facility failed to ensure trash cans in the kitchen food preparation areas were covered. This had the potential to affect 79 residents in the facility. The facility identified two residents (#21 and #137) who did not receive food from the kitchen. The facility census was 81. Findings include: Observation on 03/31/25 at 8:30 A.M. revealed a trash can in the food preparation area by the stove was not covered. Interview at the same time, [NAME] #357 verified the trash can did not have a lid. [NAME] #357 stated she looked for a lid and was not able to locate one. Observation on 04/02/25 at 11:47 A.M., the trash can in the food preparation area remain uncovered. […]

• No harm, potential for more than minimal, patternF883Apr 25, 2022

  Based on medical record review, staff interview, and policy review the facility failed to offer residents influenza and pneumococcal immunizations. This affected five residents (#17, #29, #78, #330, and #339) of seven residents reviewed for immunizations. The facility census was 79. Findings include: 1. Review of Resident #17's medical record revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #17's medical record revealed no evidence the resident was offered a pneumonia or influenza vaccine. Review of the influenza and pneumonia vaccine section of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] was coded as not assessed. 2. Review of Resident #29's medical record revealed an admitted [DATE]. […]