Trinity Hill Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600May 20, 2025

  Based on a review of clinical records, facility documentation, facility policy, and interviews for one of three residents (Resident #3) reviewed for abuse, the facility failed to ensure the residents were free from abuse and failed to ensure adequate supervision to prevent a resident-to-resident altercation with an injury. These failures resulted in a finding of Immediate Jeopardy. The findings include: a. Resident #1's diagnoses included anxiety and schizophrenia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of ten out of fifteen, indicative of moderate cognitive impairment, and was self-mobile in a wheelchair. […]

• No harm, potential for more than minimal, patternF584Jun 3, 2026

  Based on observations, review of facility documentation and interviews, the facility failed to ensure resident rooms were in good repair and painted and failed to ensure proper ventilation in resident rooms that do not have an in-room air conditioning unit. The findings included:Observations on all days of the survey 5/27, 5/28, 6/1, 6/2 and 6/3/26 identified the majority of the resident rooms on the second floor identified walls that had been spackled but not painted, baseboard molding detached and peeling off of the walls, some damage to walls like holes or scrapes and marks to the walls, and exposed sheetrock that was in need of repair. All windows in the facility were nailed shut preventing them from being able to be opened. […]

• No harm, potential for more than minimal, patternF658Jun 3, 2026

  Based on observations, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for 6 sampled residents (Residents #27, #77, #78, #82, #97 and #125) who are on Methadone maintenance, the facility failed to ensure Methadone orders were transcribed correctly to reflect the Methadone that was being administered and failed to ensure the Methadone policy was followed. The findings include:Review of the clinical records for Residents #27, #77, #78, #82, #97 and #125) on 6/1/26 identified physician's orders that directed the administration of Methadone with a concentration of 10mg/5 ml. […]

• No harm, potential for more than minimal, patternF923Jun 3, 2026

  Based on observation, review of facility documentation and interviews the facility failed to ensure adequate ventilation by means of opened windows, or mechanical ventilation, or a combination of the two was in place consistently in the building. The findings include:Observations on all days of the survey 5/27, 5/28, 6/1, 6/2 and 6/3/26 identified all windows in resident rooms on the 1st, 2nd and 3rd floors had screws in the windows that prevented them from being opened at all. There are no screens in the resident room windows. Inside building temperatures on 5/27/26 ranged from 77 degrees to 81 degrees (which was within the range for regulatory expectations for internal temperature). External temperatures that day reached 85 degrees. […]

• No harm, potential for more than minimal, patternF565Oct 29, 2024

  Based on review of resident council minutes, review of facility policy, and interviews, the facility failed to provide documentation of the facility's response to resident council's grievances. The findings include: Review of the monthly resident council group meeting minutes from May 2024 to September 2024 identified the following concerns: In the May 2024 resident council meeting minutes residents voiced concerns regarding staff not folding or hanging cleaned clothing up after it was laundered, staff using cellphones while providing care, and residents not being able to choose when to be put back to bed. […]