Trinity Place

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 19, 2025

  Based on record review, observation, and interviews with staff and a resident, the facility failed to provide a safe transfer. The resident was transferred manually by stand pivot (A technique for moving where a resident stands with assistance and pivots on their feet then sits. This technique requires the ability to bear most of their body weight.) and supported under her arm pits by Nursing Assistant (NA) #1. During transfer the resident's right knee had a popping sound and the resident reported immediate pain. The resident was transferred to the hospital for an evaluation and x-ray determined the resident had a non-displaced fracture (the bone fractured but did not move out of place) of the proximal tibia-fibula (fracture of the shin and calf bone just below the knee). […]

• No harm, potential for more than minimal, patternF761Jun 8, 2023

  Based on observations, record review, staff interviews and review of the manufacturers guidelines the facility failed to discard an expired multi dose oral inhaler, and expired nebulizer solutions, and record an opened date on a nebulizer solution on 2 of 3 medication carts and failed to discard an expired influenza vaccine and nebulizer solution in 1 of 2 medication rooms reviewed for medication storage. Findings included. Review of the manufactures guidelines revealed Trelegy multi dose oral inhalers should be discarded 6 weeks after opening. Ipratropium Bromide 0.2% nebulizer solution and Levalbuterol 1.25 milligram (mg) nebulizer solution should be discarded 2 weeks after opening the foil pouch. […]

• No harm, potential for more than minimal, patternF686Dec 16, 2021

  Based on record review and staff and physician interview, the facility failed to provide pressure ulcer treatment for 1 of 1 resident (Resident #61) reviewed for pressure ulcers. The findings included: Resident #61 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #61 had a significant change Minimum Data Set (MDS) dated [DATE] which revealed she was moderately cognitively impaired with a Stage 4 facility acquired pressure ulcer. She required extensive assistance with bed mobility, toileting and eating. Resident #61 was incontinent of bowel and bladder. […]

• No harm, potential for more than minimal, isolatedF600Dec 16, 2021

  Based on record review, resident and staff interviews, the facility failed to protect a resident's right to be free from mistreatment by a staff member (Nursing Assistant #3) due to being rough while provide care and making disrespectful comments to 1 of 1 resident reviewed for mistreatment (Resident#49). The Findings included: Resident #49 was admitted to the facility on [DATE]with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annal Minimum Data Set (MDS) dated [DATE] revealed Resident #49 was cognitively intact. […]

• No harm, potential for more than minimal, isolatedF607Dec 16, 2021

  Based on record review and family and staff interviews facility staff failed to follow the facility's Abuse Investigation and Reporting for Senior Services Policy when they failed to promptly report allegations of abuse for 2 of 3 residents, Residents #113, and Resident #49, reviewed for abuse. Resident #113 reported allegations of abuse to a staff member who did not report the allegation to facility management, which resulted in the accused staff member not being removed from the facility and an investigation being delayed. Resident #49 also reported allegation of abuse to staff, and they failed to report the allegation to the Division of Health Service Regulation and failed to assess Resident #49 and investigated the allegation. The findings included: 1. […]