Trinity Rehabilitation & Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, patternF580Nov 12, 2025

  Based on observation, interviews, and record review, the facility failed to consult with the physician when the resident experienced a change in condition for 3 of 4 residents (Resident's #11, #12, and #13) reviewed for a change of condition.1. The facility failed to notify the wound care physician to obtain and implement wound care orders for Resident #11 until 10/20/25, 2 days after identifying unstageable pressure injury (a full-thickness tissue loss where the base of the ulcer is covered by slough or eschar, making it impossible to determine the depth of the wound) to right heel on 10/18/25.The facility failed to contact surgeon or wound care physician to obtain wound care orders for Resident #11 on 11/3/25 after debridement of pressure ulcer (the medical process of removing necrotic… […]

• Immediate jeopardy, patternF686Nov 12, 2025

  Based on observations, interviews, and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 4 of 4 Residents (Resident's #11, #12, #13, and #16) reviewed for pressure injuries.1. The facility failed to complete weekly skin assessments after 10/18/25 for Resident #11 who admitted on [DATE] after ORIF (Open Reduction Internal Fixation) for fracture to right foot. […]

• Immediate jeopardy, patternF760Nov 12, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure residents were free of any significant medication errors for 2 of 11 residents reviewed for medications. (Resident #4 and Resident #2)1.The facility failed to administer Metoprolol (a medication to treat high blood pressure) and Entresto (a medication to treat high blood pressure and treat heart failure) to Resident #2 on 10/6/25 at 9:00 pm as ordered.2. The facility failed to ensure Entresto 24/26 mg 1 tablet by mouth twice a day was ordered for Resident #4 when she was admitted to the facility from the hospital on 9/18/2025. 3. […]

• Immediate jeopardy, patternF604Nov 5, 2023

  Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from physical restraints for 1 (Resident #1) of 31 residents reviewed for physical restraints. The facility failed to inform Resident #1 or their representative of the risks associated with use of assist bars, care plan for risks associated with assist bars/bed rails, obtain consent for the use of assist bars, obtain physician orders for use of assist bars, and implement interventions following an incident of entrapment with the assist bar. Resident #1 was found by LVN A on the floor in his room with his left arm caught between the assist bar and air mattress on [DATE] and had no interventions to address risk of entrapment following incident. […]

• Immediate jeopardy, patternF607Nov 5, 2023

  Based on observations, interviews, and record reviews, the facility failed to implement policies and procedures that prohibit and prevent physical restraints of residents for 1 (Resident #1) of 31 residents reviewed for physical restraints. The facility failed to inform Resident #1 or their representative of the risks associated with use of assist bars, care plan for risks associated with assist bars, obtain consent for the use of assist bars, and obtain physician orders for use of assist bars, and implement interventions following identified entrapment incident from assist bars. Resident #1 was found by LVN A on the floor in his room with his left arm caught between the assist bar and air mattress on [DATE] and had no interventions to address risk of entrapment following incident. […]