Inspection Reports for
Trinity Homes

The complaint investigation found that Resident #1 fell out of a wheelchair during van transport on 11/17/25 due to the transporter not securing the shoulder strap seatbelt. The resident sustained a fractured femur requiring surgery. The facility's investigation confirmed the transporter forgot to secure the seatbelt while distracted. Corrective actions included suspension of the van driver, staff education, and implementation of a safety checklist.

The facility failed to provide adequate supervision and secure the shoulder strap seatbelt for one resident during van transport, resulting in a leg fracture. The facility implemented corrective actions immediately after the incident, including suspending the van driver, halting resident transport until staff education was completed, and instituting a safety checklist.

The facility was found deficient in multiple areas including resident participation in care planning, honoring resident rights regarding treatment and advance directives, timely reporting and investigation of alleged abuse/neglect, adherence to professional standards for physician orders, provision of personal hygiene and wound care, accident prevention, medication administration accuracy, infection control practices, and food safety.

The complaint investigation focused on allegations of abuse, neglect, medication errors, and infection control breaches involving multiple residents, including Resident #1's elopement and failure to report, Resident #3's fall from wheelchair, and other care deficiencies.

The facility failed to timely report and thoroughly investigate alleged abuse/neglect involving Resident #1's elopement, failed to follow physician orders for therapy evaluation, failed to provide adequate personal hygiene and wound care for residents, failed to ensure safe transfers and accident prevention, failed to provide adequate hydration assistance, had medication administration errors, failed to discard expired medications and food, and failed to follow infection control standards including proper PPE use and equipment disinfection.

The complaint investigation found substantiated sexual abuse involving two residents with severe cognitive impairment. The facility confirmed the incident occurred on 05/18/25 and took corrective actions including separating the residents, increasing staff monitoring, educating staff, and updating care plans.

The facility failed to protect two residents with Alzheimer's disease and dementia from sexual abuse, as they engaged in non-consensual sexual contact due to impaired cognitive ability. The facility implemented immediate corrective actions including increased monitoring, staff education, and updated care plans.

The investigation was complaint-driven based on a facility-reported incident where Resident #1 kicked a female resident causing her to fall. The complaint was substantiated with findings of abuse and inadequate care.

The facility failed to protect residents from abuse by Resident #1, who exhibited repeated verbal, physical, and sexual abusive behaviors. The facility also failed to adequately assess, monitor, and manage these behaviors, resulting in fear and anxiety among residents. The care plan did not address situational stressors or sexually abusive behaviors, and staff failed to report incidents consistently.

The facility failed to review and revise comprehensive care plans for multiple residents, failed to obtain physician orders and notify providers of treatment refusals, failed to provide appropriate pressure ulcer care, failed to ensure safe mechanical lift transfers, failed to provide adequate supervision resulting in injury, failed to clarify feeding tube orders and obtain updated swallowing evaluations, failed to maintain infection control practices including PPE use and hand hygiene, failed to maintain food storage equipment, and failed to monitor antipsychotic medication side effects.

The complaint investigation found that the facility failed to report the incident of serious bodily injury to the facility administration and State Survey Agency within 2 hours as required. The initial report was submitted approximately 19 hours after the fall. The resident fell from a hoyer lift on 07/26/24 at approximately 7:00 p.m., sustaining facial lacerations.

The facility failed to report a serious injury fall incident within the required timeframe and failed to provide appropriate post-fall care, including timely documentation and neurological assessments. The resident sustained facial lacerations and the facility did not document neurological checks as required by policy.

The complaint investigation was substantiated with findings that the facility failed to provide adequate supervision to prevent a fall with injury, failed to monitor and address severe weight loss, had a medication error rate exceeding 5%, and failed to secure medications properly.

The facility failed to provide adequate supervision to prevent a fall resulting in fracture injury for Resident #68, failed to monitor and address severe weight loss for Resident #315, had a medication error rate of 12% during administration to Resident #315, and failed to ensure secure storage of medications on one medication cart.

The visit was complaint-related due to allegations of inadequate supervision leading to a resident fall with injury, failure to maintain nutritional status, medication errors, and unsafe medication storage. The report documents substantiated findings of actual harm and minimal harm or potential for harm.

The facility failed to provide adequate supervision to prevent a fall resulting in fracture injury for Resident #68, failed to address significant weight loss and notify providers for Resident #315, had a medication error rate of 12% during administration to Resident #315, and failed to ensure secure storage of medications on one medication cart.