Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Care Center during CMS and state inspections, most recent first.
The facility failed to notify the provider of a significant orthostatic BP drop for one resident and failed to notify the provider after two blood glucose readings over 400 mg/dL for another resident. One resident had intact cognition, antipsychotic use, and an order for monthly orthostatic BP checks, but the EMR showed a systolic drop from lying to standing without provider notification. Another resident with type 1 DM and severe cognitive impairment had orders to update the provider for BG >400 mg/dL, yet EMR review showed readings of 498 mg/dL and 449 mg/dL with no documented provider notification.
The facility failed to complete and transmit a required DRNA MDS for a resident who was discharged home with family and home health services. The census and progress note showed the resident’s status changed to STOP BILLING and the discharge occurred, but the MDS record showed no transmitted discharge assessment. The ADON/MDS coordinator stated the discharge MDS had been missed and that he sometimes delayed submission to ensure the resident was not readmitted, then may have forgotten to complete it.
A resident with moderate cognitive impairment and a progressive neurologic condition had conflicting mobility documentation, including care plan and Kardex entries showing both non-ambulatory status and an active ambulation program. Staff interviews and a progress note showed the resident had stopped ambulating with nursing staff and the restorative program was no longer active, yet the restorative care plan still listed ambulation tasks and had not been updated to reflect the change in status.
A resident with multiple sclerosis and osteoporosis, requiring substantial assistance for transfers, was injured when a nursing assistant used the wrong size sling and failed to secure safety straps during a stand lift transfer. This improper use of equipment led to the resident falling, sustaining a head laceration and mild concussion.
The facility failed to secure medications in two observed medication carts, which were left unattended and unlocked near resident areas. A nurse and a medication aid acknowledged responsibility for the carts and confirmed they should be locked to prevent unauthorized access. The DON and facility policy both emphasize the importance of locking medication carts when not in use.
During a COVID-19 outbreak, a facility failed to ensure proper PPE practices, particularly on the Chateau Unit. Despite CDC guidance and facility policy requiring masks, a trained medication aide was observed repeatedly wearing a mask improperly while performing duties. Interviews with staff confirmed the expectation to wear masks at all times, but the aide admitted to non-compliance due to discomfort. The director of nursing verified the expectation for proper mask use, highlighting a breach in PPE protocol.
The facility did not offer or administer the PCV20 vaccine to five eligible residents, despite their medical conditions and previous vaccinations. Interviews revealed that residents and their representatives were not offered the additional vaccination, although they were willing to receive it. The nurse manager cited difficulties in obtaining a standing house order from the medical director, leading to delays in vaccination, contrary to the facility's policy to follow CDC guidance.
A resident with severe cognitive impairment and dependent on staff for all ADLs, including oral care, did not receive adequate oral hygiene. Despite the care plan requiring oral care twice daily, the resident received it only seven times over several weeks. The family member reported the lack of oral care, and staff confirmed it was not part of the typical morning routine, contrary to facility policy.
A resident with severe cognitive impairment and on Eliquis, a blood thinner, had unmonitored bruising and scabbing on the left shin. Despite care plan instructions to monitor for side effects, the facility's records lacked documentation of these skin alterations. Staff noticed the condition but did not report or document it, and the nurse manager was unaware of the issue. The facility's policy on non-pressure skin concerns was not provided.
A resident with severe cognitive impairment and dependent on staff for all ADLs did not receive routine ROM exercises as per their care plan. Observations and interviews confirmed that nursing staff failed to perform and document ROM exercises, despite the resident having stiff and contracted legs. The facility's policy required ROM exercises to maintain joint mobility.
A facility failed to ensure the proper cleaning of a CPAP machine for a resident, leading to potential risks of respiratory infection. The resident's CPAP machine was observed with a buildup of dust and a white substance, indicating a lack of daily cleaning as required by the manufacturer's guidelines. Nursing staff confirmed that only weekly cleanings were scheduled, and the nurse manager acknowledged the oversight, stating that daily cleaning should have been performed.
A resident with cognitive impairment and fall risk fell from a bed that was not in the lowest position, resulting in fractures. The care plan required a low bed and floor mat, but these were not consistently followed. Staff provided conflicting accounts of the resident's ability to use the bed remote and the presence of the floor mat.
Failure to Notify Provider of Orthostatic BP Drop and Critical Hyperglycemia
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident with orthostatic hypotension. R5’s quarterly MDS showed intact cognition, antipsychotic use, and substantial to maximum assistance with ADLs. R5 had an order for monthly orthostatic blood pressure monitoring because of antipsychotic use, and the 4/18/26 vital signs record showed a blood pressure of 122/72 lying, 118/71 sitting, and 101/62 standing, reflecting a systolic drop greater than 20 mmHg from lying to standing. The EMR did not show that the physician was notified of this orthostatic blood pressure drop. During interviews, RN-D and RN-C stated staff should notify the provider for a 20-point orthostatic drop, and RN-C stated the 4/18/26 drop had not been reported. The facility also failed to notify the physician after two hyperglycemic blood glucose readings greater than 400 mg/dL for another resident. R68’s quarterly MDS showed severely impaired cognition and substantial to maximum assistance with ADLs, and diagnoses included type 1 diabetes mellitus with other diabetic neurological complications and other frontotemporal neurocognitive disorder. R68 had an order for accuchecks three times daily with meals and to update the provider if blood sugar was less than 90 mg/dL or greater than 400 mg/dL. The EMR showed blood glucose readings of 498.0 mg/dL on 3/26/26 and 449.0 mg/dL on 4/20/26, but there was no evidence the provider was notified for either reading. RN-B and RN-A stated staff should notify the provider for elevated blood sugar readings over 400 mg/dL, and RN-A could not locate documentation of provider notification for the two events.
Missed DRNA MDS for a Resident Discharged Home
Penalty
Summary
The facility failed to ensure a discharge return not anticipated (DRNA) MDS was completed and transmitted to CMS for one resident, R23, who was discharged home with family and was to receive home health services. R23’s census listing showed the resident’s status changed to STOP BILLING on 1/6/26, and a progress note the same day documented the discharge home. Review of the MDS listing dated 12/16/25 showed no record that the required DRNA MDS had been transmitted for the discharge. During interview, the ADON/MDS coordinator stated the discharge MDS had been missed and explained that he sometimes waited a few days to submit a discharge MDS to make sure the resident was not readmitted, and then may have forgotten to complete the assessment. The facility’s MDS 3.0 Assessment policy dated 8/20/24 stated that a discharge assessment should be completed within 14 days of discharge.
Care Plan Not Updated for Resident’s Change in Ambulation Status
Penalty
Summary
The facility failed to revise R42’s care plan to reflect changes in ambulation status. R42’s quarterly MDS indicated moderate cognitive impairment, partial to substantial assistance with ADLs, and that walking was not attempted during the assessment period. R42 had a diagnosis of a progressive neurologic condition and was not on a ROM or walking program at that time. R42’s care plan history showed conflicting and outdated mobility information. One care plan for risk for decline in ambulation stated R42 would ambulate 10-20 feet three times per week with a gait belt, front wheeled walker, and assist of 2 with a wheelchair following. A later mobility care plan stated R42 was non-ambulatory and required ROM exercises twice daily, while the self-care deficit care plan indicated transfer with 2 assist and sit-to-stand mobility. The Kardex also listed R42 as non-ambulatory with ROM twice daily and assist of 2 for transfers with a sit-to-stand lift, but it still included an ambulation task to encourage and assist walking 10-20 feet with a front wheeled walker, gait belt, and assist of 2 three times per week. Documentation and interviews showed R42 had stopped participating in ambulation with nursing staff and the restorative program was no longer active, yet the ambulation task remained in the charting system. A progress note stated R42 preferred not to ambulate with staff and would remain non-ambulatory going forward per her preference. Staff interviews confirmed R42 had been refusing ambulation since late December 2025 or January 2026, that the restorative nurse realized the ambulation task was still active, and that the task should have been removed when the program was discontinued. The restorative nurse and RN confirmed the restorative care plan still reflected an ambulation program even though R42 was not currently participating.
Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a nursing assistant failed to provide a safe transfer for a resident who required the use of a stand lift. The resident, who had diagnoses including multiple sclerosis and osteoporosis, was cognitively intact and required substantial assistance with transfers. The care plan specified the use of a medium-sized sling with the stand lift and assistance from one staff member. However, the nursing assistant used a large sling instead of the prescribed medium size, did not secure the waist or calf straps, and failed to ensure all loops were properly attached to the lift. During the transfer, after assisting the resident with toileting and perineal care, the nursing assistant attempted to move the resident out of the bathroom using the stand lift. At this point, one of the sling loops detached from the lift, causing the resident to fall and strike her head on the floor. The resident sustained a laceration to the back of her head, resulting in active bleeding, and was subsequently diagnosed with a mild concussion and required stitches. Interviews confirmed that the nursing assistant did not follow the care plan or facility policy regarding the use of mechanical lifts, specifically by using the incorrect sling size and not securing the required safety straps. The incident was attributed to improper use of the lift and harness, as verified by staff and a representative from the lift manufacturer. The resident's transfer status was later changed following reassessment, but the deficiency was directly related to the failure to follow established procedures for safe transfers.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure the secure storage of medications in two of the six medication carts observed. On two separate occasions, surveyors observed unattended and unlocked medication carts outside nursing stations in units named The Cottages and The Chateau. These carts were located near areas with several residents present, posing a risk of unauthorized access to medications. During the first observation, a registered nurse (RN-A) acknowledged responsibility for the unlocked cart and confirmed that medication carts should be locked when unattended to prevent access by unauthorized staff, residents, and visitors. In the second instance, a trained medication aid (TMA-A) verified responsibility for another unlocked and unattended medication cart. TMA-A confirmed that the cart should be locked to prevent medication errors and unauthorized access. The director of nursing (DON) stated that medication carts are expected to be locked when unattended to prevent access by unlicensed personnel or residents. The facility's policy on medication administration, dated 8/7/23, requires that medication carts be stored in designated areas and locked when not in use, with the nurse or TMA retaining the key while on duty.
Improper PPE Use During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure proper personal protective equipment (PPE) practices during a COVID-19 outbreak, specifically on the Chateau Unit. The Centers for Disease Control and Prevention (CDC) guidance requires source control measures, such as wearing masks, during an outbreak. Despite signage at the facility entrance indicating a COVID outbreak and the requirement for masking, observations revealed non-compliance with these measures. A trained medication aide (TMA-A) was repeatedly observed with a surgical mask improperly worn, either below the nose or chin, while performing duties such as obtaining and administering medications and moving through resident areas. This occurred despite the facility's policy and the infection control preventionist's statement that all staff were required to wear surgical masks at all times, with additional PPE required when entering COVID-positive rooms. Interviews with various staff members, including nursing assistants, housekeepers, and nurses, confirmed the understanding that masks should be worn at all times in resident areas to prevent the spread of infection. However, TMA-A admitted to not wearing the mask properly due to discomfort, acknowledging the vulnerability of the residents. The director of nursing verified the expectation for all staff to wear masks appropriately, highlighting a breach in PPE protocol as identified in the facility's policy.
Failure to Offer Recommended Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that recommended pneumococcal vaccinations, as outlined by the CDC, were offered and/or provided to five residents reviewed for immunizations. These residents, who had various medical conditions such as impaired cognition, kidney disease, diabetes, dementia, heart failure, heart dysrhythmia, and hypertension, had previously received the PPSV23 and PCV13 vaccines. However, the facility did not offer or administer the PCV20 vaccine to these residents prior to the survey entrance, despite their eligibility for it. Interviews with resident representatives and the residents themselves revealed that they were not offered the additional pneumococcal vaccination, and they expressed willingness to receive it if it had been offered. The infection preventionist indicated that the nurse manager was responsible for tracking and offering pneumococcal vaccinations. The nurse manager acknowledged that the residents were eligible for the PCV20 dose but cited difficulties in obtaining a standing house order from the medical director, which led to delays in offering and administering the vaccination. The facility's Resident Immunization policy stated that pneumococcal vaccines would be offered according to current CDC guidance, which was not adhered to in this case.
Failure to Provide Adequate Oral Care to Dependent Resident
Penalty
Summary
The facility failed to provide adequate oral care to a resident with severe cognitive impairment who was dependent on staff for all activities of daily living, including oral hygiene. The resident, who was unable to take any food or fluids by mouth and required a gastrostomy tube for nutrition, was observed to have received oral care only seven times over a period of several weeks. Despite the care plan specifying the need for oral care twice daily, the nursing assistants and registered nurse involved in the resident's care did not perform oral care during their morning routine, as confirmed by their statements and observations. The resident's family member, who spent significant time with the resident, reported that oral care was not being performed as required, despite education provided by speech therapy to the nursing staff. The facility's policy on oral hygiene, which was revised in May 2023, indicated that all residents should receive oral care as defined by their care plan to promote cleanliness and prevent oral infection. However, the staff's failure to adhere to this policy and the care plan resulted in the deficiency noted in the report.
Failure to Monitor Skin Alterations in Resident on Blood Thinner
Penalty
Summary
The facility failed to monitor bruising and scabbing on a resident's left shin who was on a blood thinner. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, was on Eliquis, a blood-thinning medication. Despite the care plan instructing staff to monitor for potential side effects of Eliquis, including excessive bruising, the resident's electronic medical record lacked documentation of any wounds being monitored. Observations and interviews revealed that the resident had multiple bruises and scabs on the left shin, which were not documented or addressed in the facility's records. Interviews with staff indicated that the bruising and scabbing had been noticed by both a nursing assistant and a licensed practical nurse, who attributed the condition to the resident's tendency to run his shins into objects and pick at his skin. However, these observations were not reported or documented as required by the facility's procedures. The nurse manager confirmed that she was unaware of the skin alterations and emphasized the importance of monitoring such conditions. The facility's policy on non-pressure skin concerns was requested but not provided, indicating a potential gap in policy adherence or availability.
Failure to Provide Routine ROM Exercises
Penalty
Summary
The facility failed to provide routine range of motion (ROM) exercises for a resident with severe cognitive impairment who was dependent on staff for all activities of daily living (ADLs). The resident's care plan, dated July 22, 2022, specified that ROM should be performed daily during dressing. However, observations and documentation from July 1, 2024, to July 23, 2024, showed no evidence of nursing assistants providing ROM to the resident. Interviews with the resident's family member, who spent extensive time with the resident, confirmed that no ROM exercises were observed being performed by the nursing staff. Further observations on July 24, 2024, revealed that during routine morning care and dressing, nursing assistants and a registered nurse did not perform ROM exercises on the resident, despite the resident having stiff and contracted legs. The registered nurse and restorative nurse confirmed that staff were instructed to provide ROM during dressing and should document it under Observations by Resident. The facility's policy on ROM, revised on November 8, 2013, indicated that the restorative ROM program was intended to maintain and improve joint mobility, with exercises to be repeated 10 times per joint when care planned.
Failure to Properly Clean CPAP Machine
Penalty
Summary
The facility failed to ensure proper cleaning of a non-invasive ventilation machine for a resident using a CPAP machine, which could lead to complications such as respiratory infections. The ResMed AirFit F20 Full Face Mask User Guide and the ResMed AirSense 10 User Guide provided specific cleaning instructions, including daily cleaning of the mask and weekly cleaning of the machine and its components. However, the facility's records and observations indicated that the CPAP machine was not cleaned daily as required. The resident, who had intact cognition and required assistance with personal care, reported that the CPAP machine appeared unclean, and observations confirmed the presence of a white substance and dust on the machine and mask. Interviews with nursing staff revealed that the CPAP machine was scheduled for weekly cleanings, but daily cleanings were not performed. A registered nurse acknowledged the mask appeared dirty and confirmed that daily cleaning was not part of the routine. The nurse manager admitted that the CPAP machine should be wiped down daily and expressed that the buildup of grime was unacceptable. The facility's policy on cleaning and disinfecting resident care equipment emphasized that respiratory therapy equipment should remain free from microorganisms, highlighting the deficiency in maintaining the CPAP machine's cleanliness.
Failure to Implement Fall Precautions Leads to Resident Injury
Penalty
Summary
The facility failed to implement care-planned fall precautions for a resident who was moderately cognitively impaired and dependent on staff for activities of daily living and transfers. The resident's care plan included interventions such as a low bed with a bedside mat due to their risk for falls. However, on the night of the incident, the resident was found on the floor with injuries, including a fractured humerus and tibia, after falling from a bed that was not in the lowest position, and without a floor mat in place. Interviews and document reviews revealed that the nursing assistant responsible for the resident's care had raised the bed to a working height to check the resident's incontinent brief and forgot to lower it back down. Additionally, there was confusion among staff about whether the resident could use the bed remote to adjust the bed height, with some staff believing the resident could and others stating they could not. The absence of the floor mat was also noted, with staff providing conflicting accounts of its presence in the room. The resident had been experiencing increased hallucinations and agitation, which contributed to their fall risk. Despite being care-planned for a low bed and floor mat, these interventions were not consistently followed, leading to the resident's fall and subsequent injuries. The facility's policy on fall prevention and management emphasized the importance of environmental rounds to minimize accidents, but these measures were not effectively implemented in this case.
Removal Plan
- Nursing leadership reeducated all staff.
- Education included expectations for rounding and lowering beds.
- NA-A was educated by the DON and provided a written warning.
- Bed height and floor mat audits were conducted.
- An interdisciplinary team meeting was conducted to review R1's fall.
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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 Farmington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Apple Valley Village Health Care Center | 7.8 mi | ★★★★★ | 1 | 0 |
| Ebenezer Ridges Geriatric Care Center | 10.5 mi | ★★★★★ | 4 | 0 |
| Three Links Care Center | 12.8 mi | ★★★★★ | 1 | 1 |
| Martin Luther Care Center | 14.1 mi | ★★★★★ | 0 | 0 |
| Augustana Care Hastings Health And Rehabilitation | 14.5 mi | ★★★★★ | 2 | 1 |
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