Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Trinity Hospital Skilled Nursing Facility during CMS and state inspections, most recent first.
A resident with intact decision-making ability and a history of depression was given a combination of IM haloperidol, lorazepam, and diphenhydramine for agitation, a "B52" regimen the DON acknowledged is typically used in ER settings and rarely in this facility. Despite AGS Beers Criteria and Epocrates identifying these drugs and their combination as high risk for older adults, the record lacked documentation of recent behaviors before or after administration, non-pharmacologic interventions, or ongoing monitoring that night. There was no behavior-focused care plan, no IDT review, and informed consent forms for each drug listed only "severe agitation" without specific behaviors or alternative treatments and risks, contrary to facility policies on psychotropic use, behavioral assessment, informed consent, and change-in-condition assessment.
Failure to maintain required RN coverage. PBJ staffing records showed multiple days across several quarters when no RN was on duty for the required 8 hours per day, 7 days per week. During interview and record review, the DON confirmed the facility did not have a full-time RN seven days a week, eight hours a day.
Unsanitary kitchen conditions were observed when the steam table and attached cutting board had rust, burnt food, dirt, dried drip marks, and stained cracks, while serving dishes on the shelf also had white food particles. The floor around the steam table had heavy dirt, grime, dried food particles, and rust, and the walk-in refrigerator condenser brackets had dirt, grime, discoloration, and peeling paint. The DM confirmed these conditions were unsanitary and could cause infection control issues and cross-contamination.
Incomplete topical NSAID orders lacked dosage details. Two cognitively intact residents received Diclofenac Sodium/Voltaren External Gel 1% orders without a specified dose quantity; an LPN used the manufacturer’s dosing card to measure one resident’s application, and the DSD and pharmacist confirmed the orders did not include the dosage information required by professional standards.
The facility failed to provide an RN for eight consecutive hours a day, seven days a week, as required. A review of the PBJ for multiple fiscal quarters in 2024 revealed numerous dates with no RN on duty. Interviews with the CEO and CNO confirmed the absence of an RN dedicated to overseeing resident care for the required hours, impacting the quality of care.
Use of High-Risk Sedating Drug Combination Without Required Assessment or Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary medications when a combination of three drugs—intramuscular haloperidol 5 mg, lorazepam 2 mg, and diphenhydramine 50 mg—was ordered and administered nearly simultaneously for agitation. The resident was an older adult with a diagnosis including depression and a BIMS score of 15/15, indicating intact decision-making ability. On the identified night, the Medication Administration Record showed that diphenhydramine and lorazepam were given at 1:01 a.m. and haloperidol at 1:02 a.m. The DON confirmed this was a "B52" combination commonly used in emergency room settings for severe agitation and acknowledged she had never seen it used in this skilled nursing facility. The facility pharmacist stated that this combination should generally be avoided in the skilled nursing setting. The facility’s own policies and nationally recognized clinical resources highlighted concerns with this medication regimen. The AGS 2023 Beers Criteria listed haloperidol, lorazepam, and diphenhydramine as medications best avoided in most older adults, with haloperidol associated with increased stroke risk, lorazepam with increased falls and fractures, and diphenhydramine with increased confusion and falls. Epocrates indicated that using these three medications together should be avoided due to risks of respiratory depression and psychomotor impairment. Facility policies on psychotropic medication use and behavioral assessment required that pertinent non-pharmacological interventions be attempted and documented, that staff observe and document the effectiveness and adverse consequences of psychotropic medications, and that physicians change or stop problematic medications or clearly document why benefits outweigh risks. Despite these requirements, the resident’s record lacked documentation of behaviors in the days immediately before or after the medication administration, and there was no documentation of non-pharmacological interventions attempted prior to giving the three medications. The progress note from the night of administration described the resident screaming, yelling, blocking the room entrance with his wheelchair, wheeling to the nursing station, and glaring at staff and other residents, and stated that the medications were effective, but there was no further monitoring documented for the remainder of the night. There was no care plan addressing behavior monitoring or the use of haloperidol, lorazepam, or diphenhydramine, and no documentation of an IDT meeting to discuss this medication use. Informed consent forms for each of the three medications listed only "Severe Agitation" as the diagnosis or signs and symptoms, without specifying behaviors to be monitored or alternative treatments and risks as required by the facility’s informed consent policy. The DON also acknowledged that a change in condition assessment was not completed following the resident’s behaviors and the administration of the three medications, contrary to the facility’s policy requiring documentation and comprehensive assessment when there is a significant change in a resident’s physical or mental condition. The Medical Director stated that the combination of haloperidol, lorazepam, and diphenhydramine is standard for enforced sedation for people who are out of control and confirmed that it was intentionally used in this case in the skilled nursing setting rather than transferring the resident to the emergency room. A subsequent progress note by the Medical Director several days later documented that the resident had been administered the three medications once that night and "has been fine ever since." However, there was no contemporaneous documentation of monitoring for efficacy and adverse consequences as required by the facility’s behavioral and psychotropic medication policies, and no evidence in the record that the physician documented why the benefits of this high-risk combination outweighed the known risks in an older adult. Collectively, these omissions and the use of a high-risk drug combination without required assessments, non-pharmacologic attempts, monitoring, care planning, and complete informed consent constituted the deficiency in ensuring the resident’s drug regimen was free from unnecessary drugs.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty 8 hours every day for 7 days a week. Review of the Payroll Based Journal (PBJ) staffing records showed multiple days in Fiscal Year Quarter 4 of 2024, Fiscal Year Quarter 1 of 2025, and Fiscal Year Quarter 2 of 2025 when no RN was on duty, including numerous Saturdays, Sundays, and other weekdays. During a concurrent interview and record review on 9/5/25 at 11:00 am, the Director of Nursing reviewed the PBJ report and confirmed that the facility did not have a full-time RN seven days a week, eight hours a day.
Unsanitary Kitchen Equipment, Floors, and Walk-In Refrigerator Surfaces
Penalty
Summary
Food preparation equipment was not sanitary, dietary staff did not maintain clean floors, and foods were stored near unsanitary surfaces in the walk-in refrigerator. During the initial tour, the steam table had a build-up of rust and dark burnt food around its body on three sides, and the attached stainless steel shelf below had rust, white food particles, dirt, and dried paint drops. Two shallow serving dishes and one deep serving dish with a lid were sitting on the shelf with white food particles on them, and the shelf edges had dried food drip marks. The long plastic cutting board attached to the steam table was stained yellow with darker yellow-brown spots, and its cut marks and cracks were stained dark. The Dietary Manager confirmed that the condition of the steam table and cutting board could cause infection control issues. The floor around the steam table had a heavy build-up of hard dirt and grime, dried food particles, and rust around the legs and underneath the steam table. In the walk-in refrigerator, the supporting structure for the condenser had a build-up of dirt and grime, including an off-white/light yellow coating with dark grime on the left bracket and peeling white paint with an off-white dirt and grime coating on the right bracket. The Dietary Manager confirmed that the dirt and grime, as well as the discoloration on the condenser brackets, could be an infection control issue and stated that the steam table, floors, and condenser brackets were unsanitary and could cause cross-contamination and infection control issues. Maintenance also confirmed that the dirt and grime build-up and peeling paint on the condenser brackets could be a cause for cross contamination and infection control issues.
Incomplete topical NSAID orders lacked dosage details
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents when Diclofenac Sodium External Gel 1%/Voltaren External Gel 1% was ordered, dispensed, and administered without complete order details, including the dosage quantity required by professional standards. The report states that medication orders are to include the name, quantity or specific duration of therapy, dosage, and time or frequency of administration, and that medications must be administered safely with the right dosage verified before administration. Resident 1 was admitted with diagnoses including other specified arthritis, fibromyalgia, and diabetes mellitus, and was cognitively intact with a BIMS score of 15/15. During observation and record review, a nurse was seen using the manufacturer's dosing card to measure the topical gel for Resident 1 because the provider order did not include a precise dosage, and the nurse stated she had never seen an order from the medical provider with the precise dosage provided. Resident 8 was admitted with diagnoses including adult failure to thrive, chronic lymphocytic leukemia of B cell type, and anemia, and was cognitively intact with a BIMS score of 14/15. Review of Resident 8's order details showed Voltaren External Gel 1% ordered for general application every 6 hours as needed, but the order also lacked a dosage. The DSD and pharmacist both confirmed that the orders did not include dosages and that the professional standard requires at least a maximum dosage in grams.
Failure to Provide RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours a day, seven days a week, as required. This deficiency was identified through a review of the Payroll Based Journal (PBJ) for multiple fiscal quarters in 2024. The review revealed numerous specific dates across these quarters where no RN was on duty, indicating a consistent failure to meet the staffing requirement. This lack of RN coverage had the potential to adversely affect all residents' quality of life and quality of care. Interviews conducted with the facility's Chief Executive Officer (CEO) and Chief Nursing Officer (CNO) confirmed the absence of an RN dedicated to overseeing resident care for the required hours. Both the CEO and CNO acknowledged the deficiency, corroborating the findings from the PBJ review. The absence of an RN on duty for the specified hours was a significant oversight in the facility's staffing practices, directly impacting the standard of care provided to the residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Weaverville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vibra Hospital Of Northern California D/p Snf | 29.7 mi | ★★★★★ | 0 | 0 |
| Quartz Hill Post Acute | 29.9 mi | ★★★★★ | 1 | 0 |
| Redding Post Acute | 30.9 mi | ★★★★★ | 16 | 0 |
| River Valley Healthcare & Wellness Centre, Lp | 31 mi | ★★★★★ | 9 | 0 |
| Copper Ridge Care Center | 32.1 mi | ★★★★★ | 15 | 0 |
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