Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Trinity Manor during CMS and state inspections, most recent first.
The facility failed to maintain sanitary conditions in the kitchen, affecting food storage, preparation, and serving for 40 residents. Observations revealed undated and improperly stored food items, unsanitary utensil drawers, and cracked light covers. Dietary staff confirmed these issues and acknowledged non-compliance with the facility's policies on cleaning, food storage, and labeling.
The facility failed to implement a water management program for Legionella disease, as part of their infection prevention and control program, placing 40 residents at risk. Despite having a documented Legionella Water Management Program dated August 2023, the facility did not manage waterborne pathogens, as reported by Administrative Staff A. This oversight could lead to the spread of Legionella bacteria, increasing the risk of Legionella pneumonia among residents.
Two residents in an LTC facility were administered crushed delayed-release and extended-release medications, contrary to physician orders and facility policy. Both residents had severely impaired cognition and required extensive assistance. The errors were observed during medication passes, and the involved nurse acknowledged the mistake, indicating a need for alternative administration routes.
A cognitively impaired resident accessed a malfunctioning basement door and fell down stairs, resulting in significant injuries. The door, which had been noted as not latching properly by housekeeping staff weeks prior, was not reported to maintenance. The resident, known to wander, sustained a head injury and rib fractures after the fall.
Unsanitary Food Storage and Preparation in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, affecting the storage, preparation, and serving of food for 40 residents. Observations revealed several issues, including an opened, undated plastic quart container of macaroni salad, and undated, opened, and partially used bags of diced ham and pre-cooked chicken pieces in the refrigerator. Additionally, food boxes were improperly stored on the floor of the walk-in freezer. These findings were confirmed by Dietary Staff CC, who acknowledged that the opened foods should have been dated and that food boxes should not be stored on the floor. Further observations highlighted unsanitary conditions in the utensil drawers below the coffee maker, which contained a piece of wrinkled paper towel, a brownish drip in a teaspoon, and dried food particles. The drawers under a make table had plastic bins for scoops and ladles with dried food and spills. The walk-in freezer still had boxes of food on the floor, and one of the fluorescent light covers in the kitchen was cracked. Dietary Staff BB confirmed the need for drawer cleaning and acknowledged that it was not included in the cleaning schedule. The facility's policies from 2011 regarding cleaning rotation, food storage, and labeling/dating food were not adhered to, contributing to the unsanitary conditions.
Failure to Implement Legionella Water Management Program
Penalty
Summary
The facility, with a census of 40 residents, failed to implement a water management program for Legionella disease, which is part of their infection prevention and control program. On January 22, 2025, at 4:50 PM, Administrative Staff A reported that the facility lacked a waterborne pathogen/Legionella program. The facility's Legionella Water Management Program, dated August 2023, was documented as part of the infection prevention and control program, indicating that the facility should have a water management program overseen by a water management team. The purpose of this program is to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionella disease. However, the facility failed to implement this program, placing residents at risk for contracting Legionella pneumonia.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents, identified as R19 and R21, remained free from significant medication errors during medication administration. R19, who had diagnoses including dysphagia, irritable bowel syndrome, and diabetes mellitus, was observed to have her delayed-release medication, Protonix, crushed and administered with applesauce by a licensed nurse. This action was contrary to the physician's order and the facility's policy, which stated that delayed-release medications should not be crushed. The nurse acknowledged the error and indicated a need to find an alternative administration route. Similarly, R21, who had diagnoses of dementia, dysphagia, and diabetes mellitus, was also administered her extended-release medication, Oxybutynin, in a crushed form mixed with applesauce. This was observed during a medication pass, and the nurse involved confirmed that extended-release medications should not be crushed. The facility's policy on crushing medications was not adhered to, as it requires that medications only be crushed when appropriate and safe, consistent with physician orders. Both residents had severely impaired cognition and required extensive assistance with activities of daily living. The facility's failure to follow proper medication administration procedures placed these residents at risk for adverse reactions. The facility's policy and standard guidelines clearly state that delayed-release and extended-release tablets should be taken whole, and the crushing of such medications was a significant deviation from these guidelines.
Failure to Report Malfunctioning Door Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and ensure a safe environment free from accident hazards when a malfunctioning basement door was not reported by Housekeeping/Laundry Staff C. This oversight led to a cognitively impaired resident, R1, accessing the door and subsequently falling down seven steps in her wheelchair, resulting in significant injuries. The resident, who had a history of cerebral infarction and severe cognitive impairment, was known to wander daily, as documented in her care plan and medical records. On the day of the incident, R1 was observed by Licensed Nurse B holding a stack of napkins and moving past the nurses' station. Shortly after, R1 was found on the landing of the basement stairs with her wheelchair nearby, having sustained a bump to the back of her head and pain in her upper left back. The resident reported that she was attempting to walk down the stairs when she lost her balance and fell. An X-ray later confirmed that R1 had three minimally displaced fractures in her ribs. The malfunctioning door, which had a keylock, was noted by Housekeeping Staff C approximately six weeks prior to the incident but was not reported to maintenance. The door was not latching properly, which allowed R1 to access the basement stairs. Maintenance logs showed no record of the door malfunction, and it was only after the incident that the locking mechanism was changed to prevent further access without a code.
Removal Plan
- Doorknob/lock changed, and door closure changed.
- All staff received education on Reporting malfunction or equipment not working appropriately immediately to Administration Team.
- Charge Nurses received education If there is a substantial fall (stairwell, out of transportation vehicle, fall face first out of wheelchair) and Director of Nursing/ Assistant Director of Nursing is present in the building, notify them and have them assess, too; if not present and another Charge Nurse present in the facility have the assess, also. If a resident sustains a substantial fall notify physician via phone, not a fax.
- The Medical Director notified.
- Staff members who have not had education will be educated prior to working their next assigned shift.
- An ad-hoc QAA meeting held to review this area of concern and the action plan created to ensure system is corrected and sustained.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 61 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dodge City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manor Of The Plains | 0.7 mi | ★★★★★ | 12 | 0 |
| Kansas Soldiers Home | 1.6 mi | ★★★★★ | 5 | 0 |
| Sunporch Of Dodge City | 3.1 mi | ★★★★★ | 1 | 0 |
| Southwind At Spearville | 15.3 mi | ★★★★★ | 19 | 0 |
| The Shepherd's Center | 18.2 mi | ★★★★★ | 24 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.