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 Brookdale Trinity Towers during CMS and state inspections, most recent first.
A resident with Type 1 DM and intact cognition had incomplete EHR documentation of meal intake, with multiple missed entries for breakfast, lunch, and dinner. CNAs stated they charted the percentage eaten and reported intake under 50% to the nurse, while the DON confirmed staff were supposed to record food intake every day and the facility policy required CNA documentation of amount eaten.
Delayed Comprehensive MDS Assessment: A resident admitted with a pelvic fracture, muscle weakness, and lack of coordination did not have a comprehensive MDS completed within the required 14-day timeframe. The Adm stated the MDS coordinator left on emergency leave, was later terminated for job abandonment, and that MDS work was handled remotely by Corporate staff before a contract MDS nurse started; the facility chart reflected the MDS completion deadline was the 14th calendar day after admission.
Incomplete Care Plan for ADL Assistance Needs: A resident with CHF, MDD, CKD, muscle wasting/atrophy, and OA had severe cognitive impairment and required substantial/maximal help with eating and oral hygiene and was dependent for multiple other ADLs. Her care plan listed an ADL self-care deficit and bathing/repositioning interventions, but it did not reflect the specific ADL assistance needed. The MDS Nurse and ADON both stated the ADLs and assistance needed should have been included in the care plan.
Care plan not updated after catheter discontinued. A resident with severe cognitive impairment, dementia, and urinary retention no longer had an indwelling catheter, but her care plan still listed one related to neurogenic bladder. Staff stated the catheter had been removed after she tried to pull it out and that she was urinating in her brief without retention, yet the MDS Nurse and ADON both said the care plan should have been revised to reflect the change.
Missed Ordered Weekly Weight Monitoring: A resident with severe cognitive impairment and a nutritional care plan had physician orders for admission weight plus weekly weights x3. The resident was weighed on admission and once weekly, but the final ordered weight was not obtained by staff. The record also showed a notable drop in weight during the monitoring period, and the ADON stated she did not know why the last weight was missed.
Expired OTC medication was found stored in backstock cabinets in both the 4th floor and 5th floor med rooms. Surveyors observed unopened bottles of Geri-Tussin with an expired date, and the ADON stated expired meds should not have been in the storage cabinet and that the central supply clerk had stocked the shipment without noticing the expiration.
Food storage practices were deficient in the kitchen freezer and in a resident food/drink refrigerator in a med room. Open boxes of raw dinner rolls, breaded chicken tenders, and breaded fish were found exposed to air, and a container of Butter Chicken Soup in the refrigerator was past the 3-day opened-date limit. The refrigerator also had sticky residue in the bottom, and staff acknowledged the food should have been sealed, labeled, and discarded per policy.
Infection Control Deficiency in Medication Storage Room: The facility failed to maintain an infection prevention and control program when unused IV infusion tubing was found out of its packaging in a drawer with sterile supplies, and a used oxygen humidifier bottle with attached tubing was stored in the medication room cabinet with other oxygen supplies. The ADON stated opened or used supplies should not have been in the room, and the IP stated the IV tubing was not to be used once removed from packaging and the humidifier should have been discarded after use.
A resident with a recent femur fracture, surgical wound, and history of falls was admitted for post-surgical care and therapy. The facility did not complete a comprehensive care plan within the required timeframe, omitting specific interventions for the fall with injury, fall mats, and surgical wound care. Staff interviews revealed confusion about care plan deadlines, and key interventions were still being added after the deadline.
The facility's main and satellite kitchens failed to maintain cleanliness and adhere to food service safety standards. Observations revealed scaling and debris in steam table wells, improper storage of personal items, and a lack of cleaning schedules. Additional issues in the main kitchen included uncovered spices, sticky substances on equipment, and improper storage practices. Staff interviews confirmed the absence of monitoring and faulty equipment, with corporate denying requests for repairs. Despite some training efforts, the facility struggled to maintain sanitary conditions.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds and infections, as observed by the absence of EBP signs and improper use of protective equipment by staff. This deficiency was noted in residents with conditions requiring additional precautions, such as open wounds and antibiotic treatments, yet necessary measures were not in place, leading to potential cross-contamination risks.
The facility failed to maintain safe kitchen equipment, with issues including a chest freezer with ice build-up and mold, a non-functional char broiler connected to a gas line, and dented equipment in the main and satellite kitchens. The maintenance process was ineffective, relying on verbal communication, leading to unresolved safety hazards.
The facility failed to include oxygen therapy in the care plans of two residents, despite physician orders and observations confirming its use. This oversight was acknowledged by staff, who indicated that care plans should reflect all treatments to ensure accurate and up-to-date care. The facility's policy requires comprehensive care plans to describe treatments and services for residents' well-being, which was not followed in these instances.
Incomplete Documentation of Resident Meal Intake
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records for 1 of 6 residents reviewed, specifically failing to document the amount of food a resident ate during meals on multiple occasions. Resident #1 was a female admitted with a diagnosis of Type 1 Diabetes, and her admission MDS assessment showed a BIMS score of 13, indicating intact cognition. Her comprehensive care plan identified diabetes mellitus as a focus and included a dietary consult for nutritional regimen and ongoing monitoring. Record review of the resident’s EHR showed several meals were not documented during March 2026. The resident had only 1 meal documented on 8 dates and only 2 meals documented on 2 dates, leaving 10 instances where meal intake was not recorded for breakfast, lunch, or dinner. CNAs stated they charted the percentage of food eaten in the EHR and reported intake of less than 50% to the nurse, and the DON stated staff were supposed to record food intake for breakfast, lunch, and dinner every day. The facility policy titled Routine Clinical Documentation required CNA documentation of amount eaten as part of daily routine clinical documentation.
Delayed Comprehensive MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive MDS assessment within 14 calendar days after admission for one resident. Resident #70, an [AGE]-year-old female, was admitted on [DATE] with diagnoses including fracture of the superior rim of the left pubis, muscle weakness, and lack of coordination. Her MDS assessment was documented as completed and signed on 04/23/26, which was beyond the required 14-day timeframe after admission. During interview, the Adm stated the MDS was supposed to be completed within 21 days from admission and explained that the facility MDS coordinator left on emergency leave on 04/06/26 and did not return, leading to termination for job abandonment on 04/15/26. The Adm also stated that an MDS Coordinator from Corporate Office worked remotely on MDSs from 04/20/26 to 04/24/26, and that a contract MDS coordinator was obtained on 04/24/26 with a start date of 04/27/26. The contract MDS nurse stated she had only been working at the facility for 2-3 days and had been advised to refer questions back to the facility. The chart provided by the facility reflected that the MDS completion date was no later than the 14th calendar day of the resident's admission.
Incomplete Care Plan for ADL Assistance Needs
Penalty
Summary
Facility failed to develop and implement a comprehensive person-centered care plan for Resident #60 that included measurable objectives and time frames to meet her medical, nursing, mental, and psychosocial needs. Resident #60 was a [AGE]-year-old female admitted with diagnoses including CHF, major depressive disorder, CKD, muscle wasting and atrophy, and unspecified osteoarthritis. Her MDS assessment dated 04/16/26 reflected a BIMS score of 3, indicating severe cognitive impairment, and showed she required substantial/maximal assistance for eating and oral hygiene and was dependent for toileting hygiene, shower/bathe, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Her care plan, dated 04/28/26, identified an ADL self-care performance deficit and included interventions for preferred bathing on Monday, Wednesday, and Friday and assist with turning and repositioning during routine care and as needed, but it did not reflect the ADLs with assistance needed. During interview, the MDS Nurse stated ADLs and assistance needed should have been included in the care plan. The ADON reviewed the care plan and verified the ADLs with assistance needed were not care planned appropriately, stating care plans were developed and updated as a team effort and that it was important for the care plan to be developed accurately so staff knew how to care for the resident.
Care Plan Not Updated After Catheter Discontinued
Penalty
Summary
The facility failed to review and revise the comprehensive care plan by the interdisciplinary team for Resident #7, whose care plan still reflected an indwelling catheter even though the catheter had been discontinued. Resident #7 was a [AGE]-year-old female admitted with diagnoses including unspecified dementia, acute kidney failure, hypertensive heart disease, anxiety disorder, and retention of urine. Her MDS assessment dated 01/29/26 reflected a BIMS score of 03, indicating severe cognitive impairment. The care plan dated 04/29/26 identified an indwelling catheter related to neurogenic bladder, with the plan initially started on 10/13/25 and revised on 11/08/25. During observation on 04/28/26, Resident #7 did not have a catheter and was not interviewable because she did not respond coherently to basic questions. During interviews, LVN A stated the catheter had been removed in January or February 2026 because the resident tried to pull it out and that she had been doing well without it, urinating in her brief without retention. The MDS Nurse stated the care plan should have been updated to remove the catheter, and the ADON stated the care plan should have been revised to reflect that Resident #7 no longer needed or used a catheter. The facility policy stated that care plans will be revised as information about the resident and the resident's condition changes.
Missed Ordered Weekly Weight Monitoring
Penalty
Summary
Resident #70 was admitted with diagnoses including fracture of the superior rim of the left pubis, muscle weakness, and lack of coordination. Her MDS reflected a BIMS score of 4, indicating severe cognitive impairment. Her care plan identified a nutritional problem or potential nutritional problem, with a goal of no significant weight loss or gain and interventions to monitor intake and document/report signs and symptoms of dysphagia while providing the ordered diet. Physician orders included weighing the resident on admission and then weekly for 3 weeks, along with a regular diet, regular liquids, and a dietician referral. The resident was weighed on admission and again one week later, with the recorded weights showing 145.0 lbs. and 144.2 lbs. A third weight was not obtained by facility staff as ordered. The weight summary also reflected a weight of 133.6 lbs. on the second weekly weigh-in. In interview, the ADON stated that weights were entered into TARS and monitored through a generated weight report, but she did not know why the final weight for Resident #70 was not obtained and had to review the medical record to confirm the missed weight.
Expired OTC Medication Stored in Medication Rooms
Penalty
Summary
Pharmaceutical services were not provided to meet resident needs in 2 of 2 medication rooms reviewed, specifically the 4th floor and 5th floor medication storage rooms. In the 4th floor medication room, surveyors observed 2 unopened 16 oz bottles of Geri-Tussin with an expiration date of 2025/07 stored in a cabinet with backstock OTC medications. In the 5th floor medication room, surveyors observed 1 unopened 16 oz bottle of Geri-Tussin with the same expiration date stored in a cabinet with backstock OTC medications. During interview, the ADON stated there should not have been any expired medications in the medication storage cabinet and that expired medications, if administered, may not have the desired effect or could cause illness. The ADON stated the central supply clerk had received the shipment and stocked the medication in the medication room but did not notice that the Geri-Tussin had expired. The facility record titled Storage and Expiration Dating of Medications and Biologicals stated that medications with an expired date on the label are to be stored separate from other medications until destroyed or returned to the pharmacy or supplier.
Food Storage and Refrigerator Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards in the kitchen freezer and in the resident food and drink refrigerator located in the 4th floor medication storage room. During the initial kitchen tour, the freezer was observed to contain boxes of raw dinner rolls, breaded chicken tenders, and breaded fish that were open and exposed to the air. During interview, the DA stated all kitchen staff were responsible for ensuring food was sealed and dated, and acknowledged that items in the freezer should have been sealed to prevent freezer burn. In the 4th floor medication storage room, the resident food and drink refrigerator contained a 16 oz container labeled Butter Chicken Soup with a sticky note identifying a resident and room number and asking if she wanted it, dated 4/19/2026. A sign on the refrigerator stated that all food and drink items must be labeled and discarded after 3 days once opened. The refrigerator also had a pink sticky substance in the bottom left corner and a yellow sticky substance in the bottom right corner. The ADON stated the soup was past the 3-day opened date and needed to be thrown away, and that it was not acceptable to have spilled material in the bottom of the refrigerator. The facility's Food Storage policy stated that all foods must be stored in a manner that maximizes nutrient retention, quality, and food safety.
Infection Control Deficiency in Medication Storage Room
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During observation of the 4th floor medication room, unused IV infusion tubing that had been removed from its packaging was found laying in the bottom of a drawer with other properly packaged and sterile supplies. In the same room, a 340 ml bottle of sterile water used for oxygen humidification was observed in the back left corner of the top shelf in the bottom storage cabinet; the bottle was not full, was not in a package, and had approximately 18 inches of oxygen tubing connected to it, with "1/2" written in black marker on the unattached end. The cabinet shelf also contained oxygen supplies such as nasal cannulas and oxygen masks. During interview, the ADON stated there should not have been any opened or used supplies in the storage room and she was not sure why they were there or why they had not been discarded. The IP stated IV infusion tubing was not supposed to be used if it was out of the packaging and sitting in a drawer, and that IV tubing was to be used immediately upon removal from the packaging. The IP also stated the humidifier was not supposed to be in the cabinet and should have been disposed of immediately after resident use. The facility policy stated single-use items are disposed of after a single use and disposable resident care equipment and supplies shall be immediately discarded after use.
Failure to Timely Develop and Implement Comprehensive Care Plan for Resident with Recent Fall and Surgical Wound
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan within the required timeframe for a resident with significant medical needs. The resident, an elderly female with a history of falls, muscle weakness, lack of coordination, and a recent displaced femur fracture requiring surgical intervention, was admitted for therapy and post-surgical care. Physician orders indicated the need for wound care to a surgical wound on the right femur, and the Minimum Data Set (MDS) assessment documented severely impaired cognition, a recent major orthopedic procedure, and a fracture-related fall prior to admission. Despite these findings, the care plan initiated at admission and later revised did not specifically address the fall with major injury, the presence of fall mats, or the surgical wound requiring wound care. The care plan only included general fall risk interventions such as keeping the call light within reach, prompt response to requests, encouraging appropriate footwear, medication review, therapy evaluations, and placing the bed in a low position. Observations confirmed that fall mats were in use, but these were not reflected in the care plan. Additionally, the care plan for skin integrity addressed a different issue (skin breakdown on the buttocks) and not the surgical wound. Interviews with facility staff, including the Administrator, MDS nurse, and DON, revealed confusion regarding the required timeframe for completing the comprehensive care plan. The MDS nurse and DON initially believed they had 21 days from admission to complete the care plan, but later acknowledged that it should have been completed within 7 days of the comprehensive assessment's completion. At the time of the survey, the care plan remained incomplete, with key interventions still being added after the required deadline.
Food Safety and Sanitation Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to maintain cleanliness and adhere to professional standards for food service safety across its main kitchen and satellite kitchens. Observations revealed that steam table wells in all kitchens had scaling, flaking, and black dots, with debris floating in the water. The underside of shelves above the steam tables was covered in dark brown substances, some appearing as drips. Personal items were improperly stored in the dry storage areas, and there was no cleaning schedule in place. Staff interviews confirmed the absence of a cleaning schedule and improper storage of personal items, which were supposed to be kept in designated lockers. In the main kitchen, additional issues were identified, including a sticky yellowish substance on the convection oven, trash cans, and floor blower. Spices and cornstarch were left open to air, and trash cans were uncovered, emitting a foul odor. The dry storage room door was propped open with a large rat trap, and the walk-in freezer had ice accumulation and inadequate lighting. Staff interviews revealed a lack of monitoring for cleaning tasks and improper storage practices, such as thawed raw meat placed above egg products in the refrigerator. The facility's executive chef and dining services director acknowledged the lack of cleaning schedules and monitoring, as well as faulty equipment and safety issues. The dining services director had submitted lists of needed repairs and replacements to corporate, which were denied. The registered dietician and maintenance supervisor also noted the absence of proper sanitation and equipment maintenance. Despite some in-service training and process improvement plans, the facility continued to struggle with maintaining sanitary conditions and adhering to food safety standards.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precaution (EBP) signs outside the rooms of three residents. These residents had conditions that warranted additional precautions, such as open wounds and antibiotic treatments, yet the necessary signage and protective measures were not in place. This oversight was observed during a survey, where staff were seen performing care without the appropriate protective equipment, such as gowns, which are required under EBP. Resident #15, a male with a bacterial infection and an ulcerating cancer wound, was receiving wound care without the use of a gown by the attending LVN. The LVN admitted to not wearing a gown because the resident was not on EBP, despite the presence of an open wound and antibiotic treatment. Similarly, Resident #33, who had a blister on the leg and was at risk for skin integrity issues, did not have EBP signs posted, and Resident #152, with a surgical wound and on intravenous antibiotics, also lacked the necessary precautions. Interviews with facility staff, including the ADON, IP, and DON, revealed a lack of clarity and consistency in the implementation of EBP. Staff were unsure of the criteria for EBP and the responsibilities for posting signs and using protective equipment. The facility's policy indicated that residents with open wounds, PICC lines, or infections should be on EBP, yet this was not consistently applied, leading to potential risks of cross-contamination and infection transmission.
Facility Fails to Maintain Safe Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, as observed in both the main kitchen (K2) and a satellite kitchen (SK2). In SK2, a chest type freezer exhibited heavy ice build-up on the inside walls, bottom, and lid, along with a removable black substance on the gasket, which was identified as mold. The dining coordinator acknowledged the need for defrosting and gasket replacement, but the issue persisted for 2-3 weeks without resolution. In K2, a char broiler that had been non-functional for over two years remained connected to the gas line, posing a fire hazard. Additionally, dented holding pans and a food mill were found, which could harbor bacteria and pose a risk of food-borne illness. The walk-in freezer in K2 was found with ice accumulation around the fan, boxes of food stacked to the ceiling, and inadequate lighting. The cook confirmed that boxes should be at least 6 inches from the ceiling to prevent fire hazards and that dented equipment could lead to bacterial contamination. The dining services director, who had been in the role for four months, was aware of the equipment issues and had submitted lists for repair approval but noted a lack of training records and a verbal-only maintenance request process. The maintenance supervisor, unaware of the specific issues, stated that the process for reporting repairs involved notifying the receptionist, who would use the electronic reporting system. However, the executive chef and dining services director indicated that maintenance requests were often communicated verbally, leading to unresolved issues. The administrator confirmed that performance improvement plans were initiated to address these deficiencies, but the report does not detail corrective actions taken.
Failure to Include Oxygen Therapy in Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents, which included measurable objectives and timeframes to meet their medical, nursing, mental, and psychosocial needs. Specifically, the care plans for Resident #15 and Resident #30 did not include necessary details regarding their oxygen therapy, despite physician orders and observations indicating the use of oxygen therapy for both residents. Resident #15, a male with an intact cognitive status, had a physician order for oxygen therapy at 2 liters via nasal cannula. However, his care plan did not reflect this need, even though observations confirmed he was receiving oxygen therapy. Similarly, Resident #30, a female with severe cognitive impairment, had an active order for oxygen therapy, which was not included in her care plan. Observations showed she was receiving 4 liters per minute of oxygen, but her care plan lacked any mention of this treatment. Interviews with facility staff, including LVNs, the ADON, and the DON, revealed a lack of clarity and responsibility regarding updating care plans. The staff acknowledged that the care plans should have included the residents' oxygen therapy details and that the omission could lead to nurses not providing the most up-to-date care. The facility's policy on comprehensive care plans emphasized the need for these plans to describe treatments and services to assist residents in attaining or maintaining their highest level of well-being, which was not adhered to in these cases.
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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 Corpus Christi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alameda Oaks Nursing Center | 0.8 mi | ★★★★★ | 8 | 0 |
| Windsor Nursing And Rehabilitation Center Of Morga | 1.4 mi | ★★★★★ | 4 | 0 |
| Windsor Nursing And Rehabilitation Center Of Corpu | 2.2 mi | ★★★★★ | 10 | 0 |
| San Rafael Nursing And Rehabiliation | 4 mi | ★★★★★ | 12 | 2 |
| Avir At Corpus Christi | 4.2 mi | ★★★★★ | 6 | 0 |
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