Trinity Homes

In the surveyor’s words

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

• Actual harm, isolatedF689Nov 19, 2025

  Based on record review, review of the facility reported incident (FRI) and investigation, review of competency/verification/training documents, and staff interview, the facility failed to provide supervision and assistance devices to prevent an accident for 1 of 1 sampled resident (Resident #1) injured during a facility van transport. Failure to secure the shoulder strap on the resident during transport resulted in Resident #1 sustaining a leg fracture. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include:The surveyor determined a deficient practice existed 11/17/25. The facility implemented corrective action on 11/18/25. […]

• Actual harm, isolatedF600Sep 5, 2024

  Based on record review, review of the facility reported incident, review of facility policy, and staff interviews, the facility failed to ensure residents remained free from abuse from 1 of 1 sampled resident (Resident #1) with verbal, physical, and sexual behaviors towards other residents. Failure to assess, care plan, and operationalize a plan/process resulted in fear, anxiety, pain, and an unsafe environment for all residents residing in the memory care unit. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation Policy occurred on 09/05/24. This policy, revised August 2023, stated, . Abuse: the willful infliction of injury, unreasonable confinement, intimidation . with resulting physical harm, pain, or mental anguish. […]

• Actual harm, isolatedF744Sep 5, 2024

  Based on record review, review of facility policy, and staff interviews, the facility failed to provide adequate dementia care and services for 1 of 1 sampled resident (Resident #1) with dementia and verbal, physical, and sexual abusive behaviors. Failure to adequately assess for necessary care and services and implement effective behavior management interventions resulted in a decreased level of psychosocial well-being for Resident #1 and had a negative impact on other residents. Findings include: The facility failed to provide a policy on dementia care. Review of the facility policy titled Abuse, Neglect and Exploitation Policy occurred on 09/05/24. This policy, revised August 2023, stated,. Residents who mistreat, are aggressive towards . other residents . […]

• Actual harm, isolatedF686Aug 8, 2024

  Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide appropriate treatment and services to prevent the development of a pressure ulcer for 1 of 5 sampled residents (Resident #68) with pressure ulcers. Failure to implement interventions as ordered, and ensure adequate monitoring/assessment resulted in an avoidable facility acquired pressure ulcer. Findings include: Review of the facility policy titled Skin Management -[NAME] Homes occurred on 08/08/24. This policy revised, December 2022, stated, . Nursing will follow the skin care procedures outlined below to . 2. Maintain the integrity of the resident's skin through monitoring and timely interventional skin care management . 8. […]

• Actual harm, isolatedF689Aug 8, 2024

  1. Based on observation, record review, review of facility investigation, and resident and staff interview the facility failed to provide adequate supervision to prevent accidents for 1 of 1 sampled resident (Resident #61) who required surgical intervention for an injury. Failure to provide adequate supervision during a transfer from the shower resulted in Resident #61 experiencing severe pain, a hematoma (collection of blood in a tissue) which required three hospitalization s and surgical intervention, cellulitis (infection of the skin), and increased anxiety and depression. Findings include: Review of the facility reported incident form occurred on 08/05/24. The form, dated 07/25/24, stated, . On 07/16/24 at 5:00 p.m. […]