Trinity Woods, Inc.

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880Jun 4, 2026

  Based on observation, interview, facility policy review, and Centers for Disease Control and Prevention (CDC) and the National Institute for Occupational Safety and Health (NIOSH) guidance, the facility failed to ensure staff were fit tested for N95 respirator masks annually. Additionally, the facility failed to maintain sanitary technique and prevent contamination of medication for 4 (Resident #10, #26, #38, and #44) of 5 sampled residents observed for medication administration, when the nurse touched the medications with bare hands, and the facility failed to ensure equipment used for vital sign readings (measurements including body temperature, heart rate, respiratory rate, and blood pressure that indicate the status of the body's vital functions) among multiple residents was… […]

• No harm, potential for more than minimal, patternF880Jun 15, 2023

  Based on record review and interview, the facility failed to have a documented water management plan for the prevention of water borne pathogens. The Resident Census and Conditions of Residents report, dated 06/13/23, documented 55 residents resided at the facility. Findings: A review of facility infection control policy and procedures failed to locate documentation of a water management program. On 06/15/23 at 12:13 p.m. the administrator was asked if the facility had a water management program. The administrator replied the facility did not and an organizational officer would work to develop one.

• No harm, potential for more than minimal, isolatedF684Jun 4, 2026

  Based on interview, record review, and facility policy review, the facility failed to notify a physician when a resident's vital signs were outside physician-ordered parameters for 1 (Resident #13) of 17 sampled residents. Specifically, a Physician wrote an order to be notified when Resident #13's systolic blood pressure (SBP) was above 160 millimeters of mercury (mm/Hg). The facility measured 35 blood pressure readings from 05/10/2026 through 05/31/2026 that were above 160 mm/Hg for Resident #13 that were not reported to the Physician. Findings included: A facility policy titled, Blood Pressure, Measuring, revised 01/2016, indicated, 4. Hypertension is defined as blood pressure over 140/90 mm/Hg (although the elderly often have persistent systolic readings from 140 to 160 mm/Hg [sic]. 5. […]

• No harm, potential for more than minimal, isolatedF756Jun 4, 2026

  Based on interview, record review, facility document review, and facility policy review, the facility failed to implement a pharmacy recommendation for discontinuation of an antidepressant medication for 1 (Resident #5) of 5 residents reviewed for unnecessary medications. Specifically, the pharmacist recommended to review Resident #5's sertraline 12.5 milligrams (mg) via peg-tube once daily (QD) for depression. The Medical Director (MD) agreed with the recommendation to discontinue the medication, and the facility failed to follow the order to discontinue it.Findings included: A facility policy titled, Medication Utilization and Prescribing Clinical Protocol, reviewed January 2016, revealed, The Physician, Consultant Pharmacist and staff will adjust existing medications based on their… […]