Trinity Glen

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Mar 30, 2022

  Based on observations and staff interviews, the facility failed to maintain sanitary conditions in the kitchen by not labeling and dating resealed food items; by failing to store food items off the floor; by failing to ensure kitchen equipment was clean and free from debris; by not correctly storing food service cleaning supplies; by not ensuring hair covering was worn by anyone entering the kitchen; and by not ensuring food items served at acceptable temperatures. Findings included: 1. During the initial tour on 3/27/22 at 10:32 a.m., 6-cases of food items were observed stacked in the middle of the floor in the dry storage room in the kitchen. […]

• No harm, potential for more than minimal, patternF690Mar 30, 2022

  Based on record review, observations, staff and nurse practitioner interviews the facility failed to prevent a urinary catheter bag from encountering the floor to reduce the risk of infection or injury for 2 of 2 residents (Resident #10 and #29) reviewed for urinary catheter care. The findings included: A review of the facility policy, titled: Catheter care, Urinary from the manual, LSC Nursing Services, under the section, Urinary and Renal Conditions, was conducted. On page 1, under infection control, the policy read: The catheter tubing and drainage bag should be kept off the floor. 1. Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF689Apr 2, 2026

  Based on record review and resident and staff interviews, the facility failed to provide care in a safe manner when Resident #4 rolled off the left side of her bed during incontinence care and required transfer to the hospital for medical evaluation. This was for 1 of 4 residents reviewed for accidents (Resident #4).Findings included:Resident #4 was admitted to the facility on [DATE]. The resident's diagnoses included vascular dementia, left side paralysis following stroke, and muscle weakness.Resident #4's care plan last updated on [DATE] revealed a focus area of risk for falls related to left side weakness and paralysis. […]

• No harm, potential for more than minimal, isolatedF756Apr 2, 2026

  Based on record review and Nurse Practitioner, Pharmacist and Medical Director interviews, the facility failed to act on a pharmacy medication regimen recommendation for a Resident taking aripiprazole; aripiprazole is an atypical antipsychotic medication that can be used to treat depression and for which possible side effects include tardive dyskinesia (uncontrollable abnormal movements of the face, tongue or other body parts and requires frequent assessment and monitoring). The deficient practice occurred in 1 of 5 residents reviewed for unnecessary medications (Resident #14).Findings included:Resident #14 was admitted to the facility on [DATE] with diagnoses including depression.Review of records revealed a 1/5/26 physician's order for aripiprazole 5 mg (milligrams) by mouth once a day… […]

• No harm, potential for more than minimal, isolatedF550Mar 30, 2022

  Based on 2 of 2 dining observations, record reviews, and staff interviews, the facility failed to ensure staff were seated while assisting Resident #38 during dining. Findings included: 1a. Resident #38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #38 was severely, cognitively impaired; was total dependent on staff for eating; and had a swallowing disorder of holding food in her mouth/cheeks. The care plan revealed Resident #38 received a mechanically altered and therapeutic diet and was at high risk for weight loss. […]