Trinity Grove

In the surveyor’s words

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

• Immediate jeopardy, patternF600Aug 5, 2024

  Based 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. […]

• Immediate jeopardy, patternF607Aug 5, 2024

  Based 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. […]

• Actual harm, isolatedF600Sep 18, 2025

  Based 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. […]

• Actual harm, isolatedF600Oct 10, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF565Sep 18, 2025

  Based 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). Findings included: a. The Resident Council Agenda dated 10/28/24 indicated in the notes section of the form that the following concerns were voiced: more sugar-free desserts, updated call bell system, and call bell response time. Staff in attendance at the meeting were Social Worker #1, the Director of Nursing and the Dietary Manager. b. […]