Trinity Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF656May 30, 2024

  Based on observation, staff interview, record review and facility policy review, the facility failed to implement a comprehensive care plan for a resident exhibiting nonverbal signs of pain and a care plan to address ADL (activities of daily living) of a resident for two (2) of 19 resident care plans reviewed. Resident #29 and Resident #17. Findings Include: Review of the facility policy titled, Comprehensive Care Plans with no revision date revealed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. […]

• Actual harm, isolatedF697May 30, 2024

  Based on observations, staff and resident representative interviews, record review and facility policy review, the facility failed to ensure a resident was free from pain after exhibiting nonverbal signs of excruciating pain for one (1) or 16 residents sampled. Resident #29 Findings Include: Review of the facility policy titled, Pain Management with no revision date revealed under the Policy .The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences This review revealed under Policy Explanation and Compliance Guidelines .The facility utilizes a systematic approach for recognition, assessment, treatment and… […]

• No harm, potential for more than minimal, isolatedF641Apr 30, 2026

  Based on staff interviews, record review, and facility policy review, the facility failed to accurately complete and submit a Minimum Data Set (MDS) assessment for a resident not receiving hospice services for one (1) of 17 assessments reviewed. Resident #38 Findings include: Record review of facility policy titled, Conducting an Accurate Resident assessment dated 10/25, revealed, Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. […]

• No harm, potential for more than minimal, isolatedF880Apr 30, 2026

  Based on observation, staff interview, and facility policy review, the facility failed to ensure clean linens were transported in a manner to prevent contamination for one (1) of three (3) days of survey. Findings Include: Review of facility policy, Infection Prevention and Control Program with an implementation date of 10/2022, the policy stated, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. On 4/28/2026 at 11:34 AM, an unidentified staff member was observed transporting clean linens in a cart without a cover in the resident hallway. […]

• No harm, potential for more than minimal, isolatedF602May 30, 2024

  Based on staff interview, record review, and facility policy review, the facility failed to ensure that a resident's personal property was safeguarded, and that staff did not misappropriate property for one (1) of 56 residents residing in the facility. Resident #23. Based on actions taken by the facility on 5/23/24, this was determined to be Past Non-Compliance. Findings include: Review of the facility policy titled Abuse, Neglect, and Exploitation with a revision date of 3/15/204 revealed under, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . […]