Trinity Village

In the surveyor’s words

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

• Actual harm, isolatedF600Apr 23, 2024

  Based on record review and resident and staff interviews, the facility failed to protect resident's right to be free from abuse for 1 of 3 residents reviewed for abuse, when Nurse Aide (NA) #1 struck Resident #1 in the shoulder two times with an open hand during incontinence care, resulting in Resident #1 crying. The findings included: Resident #1 admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following a stroke and dementia with mood disturbance. Review of Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed her to be cognitively impaired without delirium, rejection of care, or instances of wandering. […]

• No harm, potential for more than minimal, isolatedF657Mar 11, 2026

  Based on record review and staff interviews, the facility failed to update and revise an individualized person-centered comprehensive care plan for 1 of 5 residents whose comprehensive care plans were reviewed (Resident #72).The findings included:Resident #72 was admitted to the facility on [DATE] with diagnoses which included non-traumatic brain dysfunction, Alzheimer's disease, non-Alzheimer's dementia, and seizure disorder.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had severe cognitive impairment and required substantial/maximal assistance (helper does more than half the effort) with the ability to roll left and right while in bed. […]

• No harm, potential for more than minimal, isolatedF689Mar 11, 2026

  Based on record review and staff interviews, the facility failed to provide care in a safe manner when a resident was rolled out of bed hitting the floor face first during incontinence care. This deficient practice affected 1 of 3 residents reviewed for accidents (Resident #72).The findings included:Resident #72 was admitted to the facility on [DATE] with diagnoses that included non-traumatic brain dysfunction, Alzheimer's disease, non-Alzheimer's dementia, and seizure disorder.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had severe cognitive impairment and required substantial to maximal assistance (helper does more than half the effort) with the ability to roll left and right while in bed.Review of Resident #72's Medication Administration Record (MAR)… […]

• No harm, potential for more than minimal, isolatedF880Mar 11, 2026

  Based on observations, record review, and staff interviews, the facility failed to follow their Hand Hygiene Policy when the Wound Care Nurse failed to doff her gloves, sanitize her hands, and don clean gloves after cleaning Resident #57's sacral wound and surrounding area and prior to cutting and placing the alginate with silver (highly absorbent wound dressing) on his wound bed during wound care. The deficient practice occurred for 1 of 8 staff observed for infection control practices (Wound Care Nurse).The findings included:Review of the facility's policy entitled Hand Hygiene which is part of the Infection Control Policies and Procedures, last revised on 10/12/23 read in part, Policy:Practicing hand hygiene is a simple yet effective way to prevent infections. […]

• No harm, potential for more than minimal, isolatedF607Apr 23, 2024

  Based on observations, record reviews, staff and resident interviews the facility failed to protect a resident from further abuse when Nurse Aide #2 witnessed NA #1 striking Resident #1 when she became combative during care and did not immediately report the incident to her supervisors which resulted in NA #1 striking Resident #1 a second time, resulting in Resident #1 crying for 1 of 3 residents reviewed for abuse. The findings included: A review of the facility's policy titled Abuse Investigation and Reporting for Senior Services last revised on 01/26/23 revealed: Retaliation by staff, regardless of whether harm was intended, is also considered abuse. The policy also stated physical abuse is defined as hitting, slapping, pinching, kicking, etcetera. […]