Trinity Oaks

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF851Oct 26, 2023

  Based on staff interview and record review the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) for the 3rd quarter in fiscal year 2023. The facility did not report accurate weekend staffing and did not accurately report licensed nurse coverage 24 hours a day. Findings included: The CMS submission report, PBJ Final File Validation Report for Fiscal Year Quarter 3,2023 (April 1 - June 30) was reviewed and indicated the facility reported excessively low weekend staffing and failed to have Licensed Nurse Coverage 24 hours per day on Sunday, 04/09/23, Saturday, 05/20/23, Sunday, 05/21/23, Sunday 06/04/23, and Sunday 06/18/23. […]

• No harm, potential for more than minimal, patternF584Feb 24, 2025

  Based on observations, resident and staff interviews, the facility failed to maintain a clean shower room for 1 of 4 shower rooms reviewed for a safe, clean, comfortable, and homelike environment (The C-Hall shower room). The findings included: An interview with Resident #8 on 2/17/25 at 2:27 PM revealed the shower room on the C-Hall where she resides was dirty and there was black mold visible on the walls. Resident #8 stated she did not like using the shower room because it was dirty, and she did not feel clean after her showers. An observation of the C-Hall shower room on 2/18/25 at 11:20 AM revealed there was a buildup of black grime observed around the shower fixtures, along the edges of the floor, and around areas on the wall where the paint was peeling. […]

• No harm, potential for more than minimal, patternF812Oct 26, 2023

  Based on observations, staff interviews, and record review the facility failed to 1) remove expired foods/foods with signs of spoilage, 2) record a label on refrigerated and frozen foods that included date of opening and use by date, and 3) store foods in sealed containers. This failure had the potential to affect all residents who received food from the dietary department. The findings included: The Use by Date Storage Chart posted on the walk-in refrigerator, recorded All food items must be properly dated and labeled and must be stored in either containers with lids, foil/film wrappers, sealed food storage bags, or their original container. […]

• No harm, potential for more than minimal, patternF814Oct 26, 2023

  Based on observations, interviews and record review, the facility failed to remove trash and debris on the ground around a commercial trash compactor and 3 of 3 commercial trash receptacles and maintain the commercial trash receptacle door closed. The findings included: During a continuous observation with the Assistant Dietary Manager (ADM) on 10/26/23 from 09:45 AM until 10:00 AM of three commercial trash receptacles and one commercial trash compactor, the door of one commercial trash receptacle was observed open, the receptacle was odorous, with multiple flies observed and the trash inside the receptacle was exposed. […]

• No harm, potential for more than minimal, patternF761Mar 30, 2022

  Based on observations, staff interviews and record review, the facility failed to discard expired medications for 3 of 3 medication carts (B hall, A hall, and C hall) and 1 of 3 medication storage rooms (C/D Medication room). Findings included: 1a. An observation on 3/29/22 at 11:58am of the medication cart on the B hall revealed one jar of [MEDICATION(S)] prescribed to Resident # 20 with an expiration date of 2/27/22. Further observation revealed Cetirizine HCL 10 mg (milligram)(antihistamine) prescribed to Resident # 15 with an expiration date of 7/21/21 and [MEDICATION(S)] HCL (antiviral) one-gram tablets with an expiration date of 7/20/21. A continued observation revealed [MEDICATION(S)] HCL (antiemetic) 4mg prescribed to Resident # 70 with an expiration date of 1/23/22. […]