Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Trace Community Care Center during CMS and state inspections, most recent first.
Inaccurate MDS Medication Coding: Two residents had MDS assessments that did not match their medication records. One resident’s MDSs coded anticoagulant use as Yes despite no anticoagulant order or MAR documentation, while another resident’s MDS coded antiplatelet use as No despite a physician order and MAR documentation for daily aspirin. The MDS coordinator confirmed the coding errors, and the DON stated MDS assessments should be accurately coded for the medications residents receive.
Medication Order Transcription Error: A resident with glaucoma had a Dorzolamide 2% eye drop order that was entered incorrectly in the EHR and MAR as 1 drop in the left eye only, while the discharge instructions and bottle label indicated 1 drop in both eyes. During observation, an LPN administered the drops to both eyes, and staff later confirmed the transcription error and that the admitting nurse did not verify the order before release.
Food storage and preparation practices were not followed when a resident refrigerator contained unlabeled or undated food and expired protein shakes were left available for resident use. Surveyors also observed staff reheating pureed food and a resident meal in the microwave without retaking temperatures after reheating, and staff confirmed the foods had been below 135 degrees and should have been checked before serving.
A staff member failed to cleanse a resident’s skin with alcohol before giving an insulin injection to a resident with Type 2 DM and an order for daily Insulin Glargine. The staff member confirmed the omission, and the DON stated staff should always cleanse the skin with alcohol before insulin administration.
Staff failed to consistently use required Enhanced Barrier Precaution (EBP) PPE, such as gowns and gloves, during high-contact care activities for two residents with a history of VRE colonization. Additionally, appropriate hand hygiene was not performed during and after incontinence care, with a staff member handling clean items and equipment without changing gloves or sanitizing hands. These actions were contrary to facility policy and posted instructions, as confirmed by staff and DON interviews.
A resident experienced an unwitnessed fall, which was not accurately coded in the MDS assessment. Despite the resident's self-report of the fall, the MDS indicated no falls had occurred. Interviews with the LPN and RN responsible for the MDS confirmed the oversight, and the DON acknowledged the error.
The facility failed to ensure accurate MDS assessments for two residents, resulting in incorrect coding of a diuretic medication and discharge destination. Staff responsible for the assessments confirmed the errors, which were also acknowledged by the DON.
The facility failed to ensure insulin pens were primed before administration, as required by both facility policy and manufacturer's guidelines. This was observed in three residents receiving insulin via Insulin Aspart FlexPens. LPNs administering the insulin were unaware of the priming requirement, indicating a lack of training or awareness. The DON and QI staff confirmed the necessity of priming, highlighting a procedural gap.
The facility failed to ensure proper storage and documentation of medications. In Med Room a, the medication refrigerator's temperature was not consistently documented. Additionally, expired Artificial Tear eye drops were found on Med Cart c, which were still available for use despite being expired. The DON confirmed that expired medications should not be administered.
A resident was discharged from an LTC facility after an emergency transfer to a hospital due to abusive behaviors. However, the facility failed to provide the required physician documentation justifying the discharge. Interviews with hospital staff and facility personnel confirmed the absence of necessary documentation, despite the resident's behavior being cited as a safety risk.
Inaccurate MDS Medication Coding
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected residents’ medication status for 2 of 16 sampled residents reviewed for resident assessment. For Resident #6, the clinical record showed an admission date of 08/19/2022 and diagnoses including cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid artery. The resident’s Annual MDS with an ARD of 05/23/2025 and Quarterly MDS with an ARD of 08/23/2025 both coded Question N0415E1, Medications: Anticoagulant, as Yes. However, review of physician orders showed a start date of 11/22/2025 for Clopidogrel Bisulfate 75 mg daily, and further review found no physician order for an anticoagulant. Review of the MAR for May 2025 and August 2025 showed no documented anticoagulant administration. For Resident #28, the clinical record showed an admission date of 07/23/2024 and diagnoses including hypertensive heart and chronic kidney disease with heart failure and atrial fibrillation. The resident’s Quarterly MDS with an ARD of 10/15/2025 coded Question N0415I1, Medications: Antiplatelet, as No. However, physician orders showed Aspirin 81 mg daily starting 12/10/2024, and the October 2025 MAR documented daily administration of Aspirin 81 mg by mouth per physician order. During interviews, the MDS coordinator confirmed the coding was inaccurate for both residents, and the DON confirmed that residents’ MDS assessments should be accurately coded for the medications they received.
Medication Order Transcription Error
Penalty
Summary
Services provided by the nursing facility failed to meet professional standards of quality when the facility did not accurately transcribe a physician’s medication order for Resident #100. The resident was admitted with a diagnosis that included glaucoma. Her discharge instructions from a prior stay documented Dorzolamide 2% ophthalmic solution, 1 drop into both eyes twice a day, but the current physician’s order in the Electronic Health Record was entered as Dorzolamide HCL Solution 2%, 1 drop in the left eye two times a day. The November and December MARs also reflected the left-eye-only order. During observation on 12/02/2025, S8STAFF administered 1 drop of Dorzolamide HCL 2% into each eye of Resident #100. In interview, S8STAFF confirmed the EHR order was for the left eye only and the bottle label read to instill 1 drop in each eye. S9STAFF later confirmed there was an error in transcription and stated the correct order was 1 drop in both eyes. S10STAFF stated she was responsible for transcribing physician orders and acknowledged she made the error. S11STAFF stated she admitted the resident and was responsible for verifying the medication orders entered into the EHR before release for administration, but she did not verify them. The DON confirmed medical records should accurately transcribe physician orders on admission and that the admitting nurse should verify the medication orders for accuracy before release.
Food Storage and Reheating Deficiencies
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During observation of a resident refrigerator in POD D's kitchenette, surveyors found a large to-go container covered with aluminum foil and a plastic container labeled with a resident's name but no date. The same refrigerator also contained 7 to 8 ounce cartons of chocolate protein shakes with an expiration date of October 2025 that were readily available for resident consumption. Facility staff and the administrator confirmed that resident food should be labeled with a date and that expired food items should not be available for residents. The facility also failed to ensure reheated food reached an internal temperature of 165 degrees Fahrenheit for 15 seconds. Surveyors observed staff reheating a plate of pureed food in a microwave and later reheating a resident meal of a hotdog, bun, and chili in a microwave, but no temperature checks were made after reheating and before serving. Staff confirmed the foods were below 135 degrees and required reheating, and acknowledged that temperatures were not retaken after microwaving. The administrator confirmed staff should take food temperatures prior to serving residents.
Failure to Follow Safe Insulin Injection Practices
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when S4STAFF failed to practice safe injection practices during insulin administration for Resident #119. The resident was admitted with a diagnosis of Type 2 Diabetes Mellitus and had a physician order for Insulin Glargine 12 units subcutaneously once daily. During an observation on 12/02/2025 at 8:35 a.m., S4STAFF injected Insulin Glargine into the resident’s left upper arm without cleansing the skin with alcohol prior to the injection. During an interview immediately afterward, S4STAFF confirmed she did not cleanse the skin with alcohol and stated she should have. The DON later confirmed that staff should always cleanse residents’ skin with alcohol prior to injecting insulin.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, specifically regarding the use of Enhanced Barrier Precautions (EBP) and hand hygiene during incontinence care for residents with a history of colonization with Vancomycin-resistant Enterococci (VRE). Observations revealed that staff did not consistently wear required personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities for residents on EBP. In two separate instances, staff members provided incontinence care and repositioned residents without donning gowns, despite clear signage and available PPE at the residents' doors. Interviews with the staff confirmed a lack of understanding or awareness of the EBP requirements. Additionally, the facility did not ensure proper hand hygiene practices during and after resident care. One staff member was observed changing a resident's soiled brief and performing perineal care, then proceeding to handle clean items, linens, and equipment without changing gloves or performing hand hygiene. The same staff member also failed to perform hand hygiene after removing gloves and before and after retrieving and using a mechanical lift for the resident. These actions were in direct violation of the facility's hand hygiene policy, which requires handwashing or use of hand sanitizer before and after resident contact, after glove removal, and after contact with bodily fluids. The residents involved had documented histories of VRE colonization and were under physician orders and care plans specifying the need for EBP. Facility policies and posted instructions clearly outlined the requirements for PPE use and hand hygiene, yet these were not followed during observed care activities. Interviews with the Director of Nursing and staff confirmed the expectations for PPE and hand hygiene, as well as the failure to adhere to these protocols during the incidents.
Inaccurate MDS Assessment for Resident Fall
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident who experienced a fall. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14, had an unwitnessed fall on November 26, 2024, which was self-reported to the staff the following day. Despite this incident, the Quarterly MDS assessment with an Assessment Reference Date (ARD) of December 3, 2024, incorrectly indicated that there were no falls since the previous assessment, leading to a failure in accurately coding the resident's fall history. Interviews with facility staff, including the LPN responsible for completing the MDS assessments and the RN who reviewed and signed off on them, confirmed the oversight. Both staff members acknowledged that the resident's fall should have been documented in the MDS assessment. The Director of Nursing also reviewed the resident's clinical record and confirmed the coding error, acknowledging that the fall should have been recorded in the MDS assessment.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate MDS assessments for two residents, leading to discrepancies in their medical records. For one resident, the Quarterly MDS assessment did not reflect the use of a prescribed diuretic, Furosemide, which had been ordered by the physician and administered twice daily since May. This oversight was confirmed by the staff responsible for the MDS assessment, who acknowledged that the medication should have been coded in the MDS. Another resident's Discharge MDS inaccurately recorded the discharge destination as a short-term general hospital, whereas the resident was actually discharged to an assisted living facility. This error was also verified by the staff responsible for the MDS assessments, who confirmed the incorrect coding. Both discrepancies were acknowledged by the Director of Nursing, who confirmed the errors in the MDS coding for both residents.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the proper dispensing and administering of insulin, as evidenced by the lack of priming of insulin pens before administration. This deficiency was observed in three residents who were receiving insulin via Insulin Aspart FlexPens. The facility's policy and the manufacturer's guidelines both require that the insulin pens be primed with 2 units of insulin before each injection to ensure proper dosing and to avoid injecting air. However, the Licensed Practical Nurses (LPNs) responsible for administering the insulin to these residents did not follow this procedure. During observations, it was noted that the LPNs did not perform the necessary air shot to prime the insulin pens before administering the insulin doses to the residents. Interviews with the LPNs revealed that they were unaware of the requirement to prime the insulin pens, indicating a lack of training or awareness of the facility's policy and the manufacturer's instructions. The Director of Nursing (DON) and the Quality Improvement (QI) staff confirmed the requirement for priming the insulin pens, highlighting a gap in the implementation of pharmaceutical procedures within the facility.
Deficiencies in Medication Storage and Documentation
Penalty
Summary
The facility failed to ensure proper storage and documentation of drugs and biologicals, as observed during a survey. In Med Room a, the medication refrigerator's temperature was not consistently documented, with records missing for several days in September 2024. This documentation was supposed to be maintained daily by the night shift nurses, as confirmed by the Director of Nursing (S1DON) during an interview. The lack of consistent temperature monitoring could potentially affect the efficacy and safety of the medications stored in the refrigerator. Additionally, expired medications were found on Med Cart c, specifically a box of Artificial Tear eye drops with an expiration date of March 2024, which was still available for use despite being opened in August 2024. The Licensed Practical Nurse (S2LPN) confirmed the expiration date and acknowledged that the eye drops should have been discarded. The Director of Nursing was informed of these findings and confirmed that expired medications should not be administered to residents.
Lack of Documentation for Resident Discharge
Penalty
Summary
The facility failed to ensure that a resident's discharge was properly documented with the required physician's justification. A resident was admitted to the facility and later transferred to a local hospital due to an emergency. The facility discharged the resident after this transfer, citing abusive behaviors as the reason. However, there was no documentation in the medical record from the physician justifying the discharge, which is a requirement. Interviews with the emergency room physician and triage nurse at the local hospital confirmed that the facility's Director of Nursing (DON) communicated that the resident could not return due to her abusive behavior and threats from her family members. The DON and the facility's administrator both confirmed the lack of documentation justifying the discharge. The medical director also acknowledged that he did not document the reason for the discharge, despite the resident's behaviors being cited as a risk to the safety of other 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 Covington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pontchartrain Health Care Center | 1.2 mi | ★★★★★ | 3 | 0 |
| Heritage Manor Of Mandeville | 2.1 mi | ★★★★★ | 5 | 0 |
| Christwood | 4.8 mi | ★★★★★ | 3 | 0 |
| Forest Manor Nursing And Rehabilitation Center | 5.3 mi | ★★★★★ | 4 | 0 |
| Lacombe Nursing Centre | 10.5 mi | ★★★★★ | 0 | 0 |
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