Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 The Graybrier Nursing And Retirement Center during CMS and state inspections, most recent first.
Surveyors found that MDS assessments were inaccurately coded for two residents, one regarding falls and the other regarding an indwelling urinary catheter. A resident with a history of muscle weakness and hip fracture had three documented falls, including one with major injury and one with no injury, but the quarterly MDS captured only a single fall with minor injury. Another resident with neuromuscular bladder dysfunction and a care plan and orders for a suprapubic catheter, including documented catheter flushes and catheter care on MARs and TARs, was coded on the quarterly MDS as not having an indwelling urinary catheter. The MDS Coordinator confirmed both coding errors after reviewing the records, and the DON stated she expected accurate MDS coding.
A facility failed to update a resident's DNR status in the EMR, despite having signed documentation indicating the DNR status. The resident's EMR incorrectly showed a Full Code status, leading to a mismatch between electronic records and physical documentation. Staff interviews revealed that the process for updating the EMR was not followed, resulting in the oversight.
A resident with Alzheimer's and dementia had sutures placed after a fall, but the facility failed to obtain an order to delay their removal. The initial order expired without completion, and no new order was documented. The Wound Care Nurse extended the removal due to the wound's appearance but did not write a new order. A nurse and hospice nurse assessed the sutures and decided not to remove them, but the nurse did not notify the NP or Medical Director, assuming the hospice nurse would. The Medical Director had instructed to leave the sutures for ten days but was unsure why the order was not updated.
A resident with dementia and limited mobility fell during a transfer due to improper use of a mechanical lift. The nursing assistant failed to cross the sling straps as per the manufacturer's instructions, causing the resident to slide out. The resident sustained minor injuries, and the incident highlighted a lapse in following proper transfer procedures.
Inaccurate MDS Coding for Falls and Indwelling Catheter
Penalty
Summary
The deficiency involves inaccurate coding of Minimum Data Set (MDS) assessments for two residents in the areas of accidents and urinary catheter use. One resident with a history of muscle weakness, a left hip fracture, and mild cognitive impairment was admitted on an unspecified date and experienced three falls between late July and October: one fall with major injury, one fall with no injury, and one fall with minor injury. However, the quarterly MDS dated in October coded only one fall with minor injury since the previous assessment, omitting the documented fall with major injury and the fall with no injury. During an interview, the MDS Coordinator reviewed the resident’s record and confirmed that three falls had occurred since the prior assessment and acknowledged that the MDS should have been coded to include one fall with no injury and one fall with major injury in addition to the minor injury fall. The DON stated it was her expectation that MDS assessments be coded accurately for accidents. The second resident was admitted with neuromuscular dysfunction of the bladder and neurogenic bladder and had physician orders dated in April to flush a suprapubic catheter with 60 cc of normal saline every shift and to provide urinary catheter care every shift. The care plan initiated in April documented the presence of an indwelling suprapubic catheter, and the December and January MARs and TARs showed that nurses consistently documented suprapubic catheter flushes and urinary catheter care every shift over several days. Despite this, the resident’s most recent quarterly MDS indicated that the resident did not have an indwelling urinary catheter. Upon review, the MDS Coordinator confirmed that the resident was coded as not having an indwelling urinary catheter and stated that an as-needed MDS nurse had coded the bladder and bowel section incorrectly, noting that the suprapubic catheter was present when the assessment was completed. The DON stated she expected MDS assessments to be coded accurately for each resident.
Failure to Update DNR Status in EMR
Penalty
Summary
The facility failed to update the Do Not Resuscitate (DNR) status for a resident with severe cognitive impairment. The resident was admitted with a Full Code status, but documentation, including a goldenrod DNR form and an Advance Directives form signed by the resident's responsible party and physician, indicated a DNR status. These forms were filed in the Code Status notebook at the nurses' station, but the electronic medical record (EMR) still reflected a Full Code status. This discrepancy was not identified during care plan meetings, as the social worker relied on the EMR dashboard, which was not updated to reflect the DNR status. Interviews with staff revealed that the process for updating the EMR with the correct code status was not followed. The medical records clerk scanned the DNR forms into the EMR, but the administrative nurse responsible for updating the dashboard did not see the paperwork. The social worker and other staff members, including nurses and nurse aides, were unaware of the mismatch between the EMR and the physical documentation. The administrator acknowledged that residents were initially considered Full Code until their code status was determined, but the failure to update the EMR led to the oversight.
Failure to Obtain Order for Suture Removal Delay
Penalty
Summary
The facility failed to obtain an order to delay the removal of sutures for a resident who had received sutures on the right side of her forehead following a fall. The resident, who was severely cognitively impaired with Alzheimer's disease and dementia, was supposed to have her sutures removed seven days after receiving them. However, the order for suture removal expired without being completed, and there was no documentation explaining why the order had expired or any further orders for suture removal in the resident's chart. The Wound Care Nurse noted that the provider had extended the order to remove the sutures due to the wound's appearance but did not write a new order. Additionally, a nurse and a hospice agency nurse assessed the sutures and decided not to remove them, but the nurse did not notify the NP or Medical Director to obtain a new order, assuming the hospice nurse would contact the provider. The Medical Director stated he had instructed the Wound Care Nurse to leave the sutures in place for at least ten days but was unsure why the order was not changed. The NP had not assessed the resident previously, as residents receiving hospice care were followed by the Medical Director.
Failure to Secure Resident in Mechanical Lift Leads to Fall
Penalty
Summary
The facility failed to secure a resident in a mechanical lift according to the manufacturer's instructions, leading to a fall. The resident, who was cognitively intact but dependent on staff for transfers due to conditions such as dementia, Alzheimer's disease, and a history of cerebrovascular events, was being transferred from her bed to a chair when the incident occurred. The manufacturer's guidelines for the U-Sling or Divided Leg Sling require the straps to be crisscrossed under the patient's legs to prevent sliding, but this step was missed during the transfer. During the transfer, two nursing assistants were present, and the resident began to slide out of the sling. The nursing assistants guided her to the floor, preventing her from hitting her head. The resident sustained an abrasion and complained of leg pain, but X-ray results showed no fractures or soft tissue swelling. The incident report and interviews revealed that one of the nursing assistants forgot to cross the bottom portion of the pad straps, which was a critical step in securing the resident properly. The unit coordinator confirmed that the nursing assistant involved had received training on mechanical lift transfers. However, the oversight in not crossing the straps led to the resident's fall. The director of nursing, who was new to the facility, was not aware of the incident but expected staff to follow the manufacturer's guidelines for using mechanical lifts.
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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 Trinity
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westwood Health And Rehabilitation | 2.5 mi | ★★★★★ | 18 | 0 |
| Westchester Manor At Providence Place | 6.5 mi | ★★★★★ | 3 | 0 |
| Magnolia Gardens Center For Nursing And Rehabilita | 6.6 mi | ★★★★★ | 3 | 0 |
| Meridian Center | 6.8 mi | ★★★★★ | 9 | 2 |
| The Shannon Gray Rehabilitation & Recovery Center | 7.3 mi | ★★★★★ | 1 | 0 |
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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.