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 Trinity Care Center during CMS and state inspections, most recent first.
A facility failed to maintain a safe, clean, comfortable, and homelike environment when three residents had bedrooms with scratches and holes in the walls near their beds and hallways had tattered floors, stained carpets, and a foul urine odor. One resident had severe cognitive impairment and preferred her bedroom, while two others had intact cognition and reported the damaged walls had been present since admission and did not feel homelike. Leadership acknowledged the poor room and hallway conditions and noted the environment could feel worn down.
Failure to Provide Needed Grooming and Hygiene Assistance: A female resident with mild cognitive impairment and two other residents with significant ADL needs were observed without needed grooming support. One resident had chin hair and said she had never been offered shaving, another had facial hair and said staff had not offered to shave her, and a male resident had long, jagged fingernails that bothered him and had not been trimmed for an extended period. Record review showed no recent ADL documentation for fingernail trimming, while CNA, LVN, DON, and ADM interviews confirmed grooming tasks were expected during shower days and monitored by nursing staff.
Controlled medication records were not accurately reconciled on three medication carts. An RN failed to document administered narcotics for one resident, another RN did not count a discharged resident’s sealed morphine bottle with the cart’s controlled meds, and a third cart had a morphine count discrepancy with an incomplete spillage entry. The DON stated the discrepancies were reported for investigation, and the facility policy required narcotics to be counted at shift change and charted after administration.
Medication Errors Exceeded Allowed Rate: During observed med passes, an MA omitted a scheduled antihypertensive for one resident because it was not on the cart, omitted Namenda for another resident because it was unavailable, and gave a third resident’s 13 scheduled meds more than an hour late. The facility’s error rate was 34.88%, based on 15 errors in 43 opportunities, and the residents involved had diagnoses including heart failure, dementia, bipolar disorder, and HTN.
Kitchen Food Storage and Sanitation Deficiencies: Surveyors observed uncovered food on a stovetop griddle, multiple unlabeled and undated food items in dry storage and the refrigerator, and several unsecured food bags on a utility cart. They also found buildup and debris in the ice scoop receptacle, ice machine, juice dispenser nozzle, convection oven front, and dish rack storage cart. Staff gave inconsistent accounts of who cleaned the equipment and how food labeling and dating were managed, while facility policies required food to be covered, labeled, dated, and stored in sanitary conditions.
Hand hygiene and glove-use failures occurred during peri-care for a resident with CHF, aphasia, functional quadriplegia, and frequent bowel/bladder incontinence, as CNA E did not change gloves between dirty and clean peri-care tasks and did not sanitize hands between glove changes while touching the resident’s environment. In the dining room, CNA F and an RN did not sanitize their hands between passing meal trays to multiple residents, and CNA F touched her face before handling a tray. Staff acknowledged the expected hand hygiene practices and the DON, ADON, Infection Preventionist, and ADM all described the facility’s hand hygiene expectations.
Unattended Computer Screen Exposed Resident MAR Information: An LVN left a medication cart computer screen open and unlocked with a resident’s MAR information visible to unauthorized individuals. The resident was a female with hemiplegia, DM2, and aphasia following cerebral infarction. The LVN acknowledged she knew the screen should be locked when stepping away, and the DON, ADON, and ADM stated staff were expected to lock or minimize charting computers when not in front of them.
A CNA accessed a resident's personal cell phone and used the resident's mobile cash app to transfer money to herself. The resident, who was cognitively intact and required minimal assistance, noticed the unauthorized transactions and reported the theft. The incident was confirmed through app records and reported to facility staff and law enforcement.
A deficiency was cited for not ensuring a resident's rights to dignity, self-determination, and communication were honored, with no further details provided about the specific circumstances or events.
The facility did not adequately accommodate the needs and preferences of a resident, resulting in a deficiency related to resident-centered care.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors during their review of facility practices.
Two residents were found without access to a working call system to request assistance, one due to a missing call light for over a week and another due to a broken and unplugged call light. Both residents had significant medical needs, and staff were unaware of the deficiencies until the time of the survey. Care plans did not address the absence of call lights, and there was no established policy or procedure to ensure timely maintenance or alternative communication methods.
Surveyors identified multiple deficiencies in food storage, labeling, and dating, as well as improper sealing and disposal of expired items. The kitchen ice machine was found with visible slime and mold, and the dry food pantry floor was dirty. Cold foods, including vanilla pudding and fruit cups, were held above safe temperatures and served to two residents, though not consumed. Staff interviews revealed inconsistent adherence to food safety policies and unclear cleaning responsibilities.
A resident with a new diagnosis of unspecified convulsions did not have this condition reflected in their care plan, despite documentation in the medical record and a recent hospital stay for seizures. The care plan lacked seizure-related problems, goals, or interventions, and staff interviews confirmed the omission, which was not in accordance with facility policy.
Surveyors found that the facility did not maintain a sanitary and accessible emergency eyewash station in the kitchen. The eyewash station was dirty, improperly covered, and blocked by clutter such as trash cans, cleaning tools, and meal carts. Staff were unaware of the station's existence or use, and there was no documented training or clear policy regarding its maintenance or accessibility.
A facility failed to update a resident's care plan to reflect a new vegetarian diet order, despite the resident's severe cognitive impairment and health conditions. The LVN responsible for the update did not amend the care plan due to other duties, although the MDS coordinator and ADM confirmed the necessity of timely updates to meet residents' needs.
A resident with severe cognitive impairment and dietary restrictions was served meat despite having a physician's order for a vegetarian diet. The facility's process for verifying meal trays was not followed due to staff being occupied with other duties, leading to the oversight. The resident's responsible party filed grievances, and the facility acknowledged the error.
A resident with severe cognitive impairment fell and sustained serious injuries after a CNA failed to report observed dizziness and left the resident unattended in the shower room. The resident, who required assistance with showering, was categorized as low risk for falls but had a care plan indicating a risk due to confusion and safety unawareness. The facility's staff were instructed not to turn their backs on residents during showers, but the CNA did not follow this protocol, leading to the resident's fall and subsequent death.
A CNA in an LTC facility failed to report a resident's dizziness and did not prepare shower supplies, leading to the resident's fall and serious injuries, including a brain bleed. The resident, who had severe cognitive impairment, was hospitalized and later placed on hospice care, eventually passing away. The facility lacked specific training and protocols for CNAs on reporting changes in condition, contributing to the incident.
The facility failed to report alleged violations and injuries within required timeframes. A resident's fall resulting in a brain bleed and broken bone was not reported to the SA within two hours, and another resident's injury of unknown source was also not reported timely. Interviews revealed a lack of awareness of reporting guidelines among staff.
The facility failed to treat six residents with respect and dignity by not serving their lunch trays at the same time as their tablemates, leading to feelings of neglect and upset among the affected residents. The issue was exacerbated by ongoing construction in the main dining hall, causing delays in meal service and a lack of adherence to the facility's policy of serving all residents at a table simultaneously.
The facility failed to ensure that residents who were unable to conduct ADLs received necessary services to maintain good grooming and personal hygiene. Four residents with various medical conditions were found with jagged fingernails and blackish/brownish substances underneath them, despite being assessed to require assistance with personal hygiene. Staff interviews revealed inconsistencies in the responsibility for nail care.
A resident with multiple health conditions was denied the right to attend a group therapy activity by a CNA, despite her care plan indicating she enjoyed such activities. The CNA incorrectly informed the resident that she could not participate because she was on hospice care, causing the resident visible agitation. Other staff confirmed that hospice residents were allowed to join group therapy activities, and the facility's policy emphasized supporting resident self-determination.
A resident with multiple diagnoses requiring extensive assistance was improperly transferred by a CNA who did not use a gait belt, causing the resident pain. Despite protocols and training in place, the CNA used her hands to pull the resident by her arms, which was not a proper transfer technique. The incident was confirmed by multiple staff members, and the CNA was subsequently blocked from working at the facility.
The facility failed to ensure a resident's hospice care order was signed and dated by the physician, leading to a deficiency in care documentation. The resident, with multiple diagnoses including multiple sclerosis and dementia, was at risk of receiving unconfirmed hospice services due to this oversight.
The facility had a medication error rate of 7%, involving two residents. One resident received a Lidocaine patch on the lower back instead of the left hip as ordered, and another resident did not receive Linaclotide for constipation due to the medication being out of stock.
Unsafe and Poorly Maintained Resident Rooms and Hallways
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for three residents by allowing scratches and holes in bedroom walls next to their beds and by allowing hallway carpets and walls to remain in poor condition. During observation, surveyors noted tattered floors, stained carpets, and a foul urine odor in the hallways on the 200, 400, and 500 halls. The report also stated that the walls and carpets in two of three observed hallways were not in good condition. Resident #26 was a female with diagnoses including hypertensive heart disease without heart failure, vascular dementia, xerosis cutis, and anorexia. Her quarterly MDS showed a BIMS score of 3, indicating severely impaired cognition. Her care plan noted that she had little interest in activities and enjoyed spending time in her bedroom. During observation, her bedroom had holes and scratches in the wall next to the head of her bed, and she stated the walls were ruined when she arrived and that the condition did not make her feel at home. Resident #16 was a female with quadriplegia and a BIMS score of 15, indicating intact cognition. She stated that scratches and holes were present in her bedroom wall when she moved in and that no repairs had been made since her arrival, and she said the room did not look homelike. Resident #17 was a male with COPD and anxiety disorder, also with a BIMS score of 15. His care plan noted little to no activity interest and a preference to stay in his bedroom. During observation, his bedroom walls had scratches and holes throughout, and he stated the holes had been there since he arrived and did not make him feel good. Facility leadership stated that maintenance work orders were used for repairs, that managers completed daily rounds, and that the conditions of the bedrooms and hallways could negatively affect residents because the environment felt worn down.
Failure to Provide Needed Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to ensure residents who were unable to perform activities of daily living received necessary grooming and hygiene assistance. During observation, interview, and record review, Resident #32, a female with diagnoses including chronic venous hypertension, major depressive disorder, and Raynaud's syndrome with gangrene, was found to have chin hair on her face. Her quarterly MDS indicated mild cognitive impairment and that she required 1-person maximum assist for ADL care, including shaving. Her care plan also identified an ADL deficiency related to weakness, polyneuropathy, and chronic pain, with substantial/maximum assist needed from one person. Resident #32 stated she had plucked her own chin hair because she had never been offered shaving at the facility and did not feel comfortable with the facial hair. Resident #100, a woman with diagnoses including essential hypertension, osteoporosis, and right shoulder pain, had severe cognitive impairment per quarterly MDS and required supervision or touching assistance for ADL care such as shaving. Her care plan identified an ADL self-care deficit related to dementia and weakness, with limited assistance from one person. During observation, she was noted to have facial hair on her face. She stated the facility had not offered to shave her face and that she did not like having facial hair. Resident #113, a male with diagnoses including dementia, COPD, heart disease, kidney disease, cognitive communication deficit, and age-related physical debility, was assessed as cognitively intact on quarterly MDS and required supervision assistance with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. During observation, his fingernails on both hands were approximately one inch long with untrimmed jagged edges and a crack at the tip of the right middle finger. He stated the long fingernails were bothering him, that staff had not asked if he wanted them trimmed, and that he was afraid of hurting himself by breaking a fingernail. Record review also showed no ADL documentation for fingernail trimming in the prior three months and no nursing progress note documentation of fingernail trimming during that period. Interviews with CNA A, LVN B, DON, and ADM reflected that fingernail trimming and facial hair care were expected to occur during shower days and be monitored by nursing staff, but the residents identified above did not receive those services as observed.
Controlled Medication Reconciliation and Documentation Failures
Penalty
Summary
The facility failed to establish an accurate system for reconciling controlled medications and maintaining drug records in order for three medication carts. During review of Medication Cart #1, RN G stated she administered Resident #5’s controlled medications but did not document the administration of one Ativan 0.5 mg tablet and one Hydrocodone-Acetaminophen 5-325 mg tablet on the narcotic record because she was busy and forgot to sign. Resident #5 was a male with diagnoses including Alzheimer’s disease with late onset, schizoaffective disorder, bipolar type, and chronic pain. His orders included Ativan 0.5 mg daily for restlessness/anxiety and Hydrocodone-Acetaminophen 5-325 mg twice daily for chronic pain, and the MAR showed the medications were given on the day in question even though they were not documented on the controlled medication record. During review of Medication Cart #2, RN H stated she did not count Resident #55’s morphine sulfate because the resident had been discharged earlier and left the medication at the facility. She stated that discontinued or discharged residents’ controlled medications should be taken to the DON for destruction and counted with the other controlled medications until properly discarded. Resident #55 was a female with diagnoses including Alzheimer’s disease, chronic kidney disease, and anxiety, with a BIMS score of 3 indicating severe cognitive impairment and hospice care noted on the MDS. Her order was for morphine sulfate concentrate 20 mg/ml, 0.25 ml by mouth every hour as needed for pain or shortness of breath, and the record showed she did not receive morphine during her stay. The bottle remained sealed and was not counted with the other controlled medications on the cart. During review of Medication Cart #3, a discrepancy was identified in Resident #148’s morphine sulfate solution count, with 27 ml in the bottle while the controlled medication log documented 28 ml. RN I stated she did not administer the medication and did not count the controlled medications at the beginning of her shift because she arrived late and another nurse had already counted the cart with the night nurse. Resident #148 was a female with diagnoses including cerebral infarction, type 2 diabetes mellitus, and major depression, and her BIMS score was 6 indicating severe cognitive impairment. The controlled log also showed a prior spillage entry of 1.5 ml with an agency nurse, but the date of the spillage was not documented. The DON stated the discrepancies were submitted to the state for investigation, and the facility’s drug diversion policy required narcotics to be counted at shift change and charted after administration.
Medication Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, with 15 errors in 43 opportunities for a 34.88% error rate. The errors involved 3 residents and 2 medication aides observed during medication administration. The report states that MA D omitted Spironolactone 25 mg for Resident #70 because the medication was not available on the cart, and the dose was not given during the observation. Resident #70 had orders for Spironolactone 25 mg once daily for hypertensive heart disease with heart failure, and the MAR showed two missed doses on 1/20/2026 and 1/21/2026. Resident #70’s record also showed diagnoses of hypertensive heart disease with heart failure, chronic systolic congestive heart failure, and permanent atrial fibrillation, with a BIMS score of 3 indicating severe cognitive impairment. The report also states that MA C did not administer Namenda 5 mg to Resident #114 because it was not available on the medication cart during the observed pass. The medication was reordered during the observation, but the resident still missed the scheduled morning dose. Resident #114 had diagnoses including unspecified moderate dementia with mood disturbance and major depressive disorder, and a BIMS score of 3 indicating severe cognitive impairment. The care plan directed staff to administer medications as ordered. In addition, MA C administered Resident #109’s 13 scheduled medications more than one hour after the ordered 8:00 a.m. administration time. The medications included Bystolic, Calcitriol, Depakote Sprinkles, Zoloft, Eliquis, Fluticasone Propionate, GlycoLax, NIFEdipine ER, Lokelma, Senna, Acetaminophen, Hydralazine, and Sodium Bicarbonate. Resident #109’s record showed diagnoses including type 2 diabetes mellitus, bipolar disorder, and hypertensive heart disease without heart failure, with a BIMS score of 12 indicating moderate cognitive impairment. The facility’s medication administration policy stated medications are to be administered within 60 minutes before or after the scheduled time.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one kitchen reviewed for sanitation. During observations, surveyors found multiple food items uncovered, unlabeled, undated, or not securely closed, including spaghetti meat sauce and winter vegetable blend on a stovetop griddle, corn chips and oatmeal in dry storage, and several items in the reach-in refrigerator such as pudding cups, nectar thick tea, red juice, orange juice, hot dogs, and lunch meat slices. Additional food storage concerns included pitchers of red juice in ice on a utility cart, dry cereal, and multiple plastic storage bags containing sandwiches, peanut butter crackers, cookies, and cheese snack crackers that were unlabeled and undated. Surveyors also observed sanitation issues with kitchen equipment and food-contact items. The ice scoop receptacle contained brown, white, and black food debris and mineral buildup. The inside lid and upper plastic shield of the ice machine had white, black, and brown substance buildup. The juice dispenser nozzle contained black, orange, red, and slimy substance on the inside. The front bottom of the convection oven had dried food debris and grease buildup, and the dish rack storage cart contained trash, food debris, and black substance. Interviews with dietary and administrative staff showed differing descriptions of responsibility for cleaning the juice dispenser nozzle, ice machine, and ice scoop receptacle, as well as for labeling and dating food items. Staff stated the juice nozzle was cleaned daily or nightly, the ice machine was cleaned by maintenance, MS, and a contract company, and food items were dated upon receipt or preparation with discard dates. However, the daily and weekly cleaning schedules reviewed only listed the ice machine under maintenance and did not include the juice machine or dispenser nozzle. Facility policies required food to be tightly covered, labeled, and dated, and required food-contact surfaces and equipment to be kept clean and sanitary.
Hand Hygiene and Glove Use Failures During Peri-Care and Meal Tray Pass
Penalty
Summary
The facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 9 of 15 residents reviewed for infection control. During peri-care for Resident #18, CNA E did not change gloves between dirty and clean peri-care tasks and did not sanitize her hands between glove changes. While assisting with repositioning, CNA E touched the bedside table, blanket, and pillow in the resident’s environment while still wearing the same gloves. Resident #18 was a female admitted with chronic diastolic congestive heart failure, aphasia, and functional quadriplegia, and her assessment showed she was frequently incontinent of bladder and bowel and required total assistance with activities of daily living. An observation of Resident #18’s peri-area showed the skin appeared red without apparent skin breakdown. CNA E stated she had received hand hygiene in-service sometime in the last year and acknowledged she was supposed to sanitize her hands between gloves and change gloves between dirty and clean peri-care areas. She also stated that not following hand hygiene could lead to cross contamination. During lunch tray pass in the dining room near nursing station C, CNA F and RN G did not sanitize their hands between passing meal trays for 8 residents. CNA F touched her face and then, without sanitizing her hands, touched the lunch tray and delivered it to residents. CNA F stated staff needed to wash or sanitize their hands between passing food trays to prevent the spread of infection and that she should have washed her hands after touching her face. RN G stated she was supposed to sanitize her hands between each resident’s tray and that not doing so could lead to potential cross contamination. The DON, ADON, Infection Preventionist, and ADM all stated staff were expected to perform hand hygiene before entering rooms, between dirty and clean tasks, between glove changes, and between each meal tray pass.
Unattended Computer Screen Exposed Resident MAR Information
Penalty
Summary
The facility failed to ensure that Resident #87’s clinical records remained protected from unauthorized viewing when an LVN left the resident’s MAR information visible on the computer screen on an unattended medication cart. During observation, the computer screen on the LVN’s medication cart on side C was open and unlocked, and Resident #87’s MAR information was displayed and visible to unauthorized individuals, including visitors or other residents who were not observed near the cart at that time. Resident #87 was a [AGE]-year-old female admitted on [DATE] with diagnoses including hemiplegia affecting the right dominant side, type 2 diabetes mellitus, and aphasia following cerebral infarction. In interview, the LVN stated she had been in-serviced on HIPAA a few months earlier and knew the computer screen should be locked when stepping away from the medication cart, and she acknowledged she was at fault for not locking it. The ADON, DON, and ADM stated staff were expected to lock or minimize charting computers when not in front of them, and the facility’s HIPAA policy and education materials stated that unattended workstations with PHI were inappropriate and that computers should be logged off or locked when walking away.
Misappropriation of Resident Funds by CNA
Penalty
Summary
A certified nursing assistant (CNA) accessed a resident's personal cell phone and used the resident's mobile cash application to transfer two separate amounts of money to herself. The incident was discovered when the resident, who was cognitively intact and required minimal assistance, noticed the unauthorized transactions and reported the theft to another CNA. The resident expressed distress over the incident, and the transactions were confirmed through photos of the cash application on the resident's phone. Interviews and record reviews revealed that the CNA had been employed at the facility following a clear background check, positive references, and a current license. Staff members, including the CNA who received the report and the social worker, confirmed that they had received annual training on abuse, neglect, exploitation, and misappropriation of funds. The facility's policy required immediate reporting of such incidents to the administrator, state agencies, ombudsman, resident representatives, and law enforcement. Despite these policies and training, the CNA was able to access the resident's property and misappropriate funds. The incident was reported to the administrator and social worker, who began gathering evidence and notified the police. The resident was later discharged from the facility for unrelated insurance reasons.
Failure to Honor Resident Rights to Dignity and Self-Determination
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these fundamental rights were upheld for the resident, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or observations related to the resident's experience.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of each resident. This deficiency was identified during the survey process, indicating that the facility did not take adequate steps to ensure that residents' individual needs and preferences were met as required.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices, which revealed lapses in the protection and management of confidential resident information and medical documentation. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Working Call Systems for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had access to a working communication system to call for assistance, as required for reasonable accommodation of resident needs. One resident, who had a history of nontraumatic intracerebral hemorrhage, acute respiratory failure with hypoxia, expressive dysphasia, and hemiplegia, did not have a call light or bell in her room from the time of admission. Observations and interviews confirmed that the resident's room lacked a call light for over a week, and neither the care plan nor staff actions addressed this absence. The Director of Nursing (DON) and other staff were unaware of the missing call light until the day of the survey, and there was no policy or procedure in place for call lights or maintenance requests. Maintenance staff had not received a request for a call light until the survey date, despite staff stating that a request had been made earlier. A second resident, with diagnoses including cerebral infarction, diabetes, arthritis, and dementia, was also found without a functioning call light. The call light cord was observed unplugged and broken, and the resident was unable to use it to request assistance. Staff were unaware of how long the call light had been nonfunctional, and the resident's care plan specifically required the call light to be within reach and for staff to respond promptly to requests for assistance. Interviews with staff and the DON revealed a lack of awareness regarding the status of the call lights and the absence of a systematic process to ensure their functionality. These deficiencies were identified through direct observation, interviews with staff, residents, and family members, and review of care plans and facility policies. The lack of a working call system in both cases was not addressed in the residents' care plans, and staff did not consistently monitor or ensure the availability of alternative communication methods when the call lights were not functional.
Deficiencies in Food Storage, Sanitation, and Temperature Control
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. Surveyors observed multiple instances where food items in the reach-in refrigerator, walk-in refrigerator, and walk-in freezer were not labeled or dated, including trays of fresh cut fruit, bags of fried okra, and containers of unidentified substances. Some food items were not properly sealed, exposing them to air and potential contamination. Expired food items were found in storage, and staff were unsure of the correct timeframes for discarding refrigerated foods. Staff interviews confirmed inconsistent adherence to labeling, dating, and sealing policies, despite training and established facility procedures. The facility also failed to maintain proper sanitation of kitchen equipment and areas. The ice machine in the kitchen was found with a black/brown slime and an unidentified substance inside the chute, with water dripping onto the ice. The prefilter was visibly dirty, and the machine had not been cleaned in over a year, contrary to manufacturer recommendations and facility policy. The dry food pantry floor was observed to be dirty, with dust, food particles, stains, and residue present. The hand-washing sink near the dishwasher was cluttered and inaccessible due to cleaning equipment and supplies blocking access. Staff interviews revealed confusion about cleaning responsibilities and a lack of regular checks on the cleanliness of the ice machine and pantry area. Additionally, the facility did not ensure that cold foods were held at safe temperatures. Vanilla pudding and fruit cups were found to be above the required 41 degrees Fahrenheit, with pudding measured at over 66 degrees Fahrenheit. Despite staff awareness of temperature requirements, these foods were served to two residents at lunch, though the residents did not consume them. Staff and management acknowledged the importance of proper food storage and temperature control, but failed to consistently implement these practices, as evidenced by observations and interviews.
Failure to Update Care Plan for New Seizure Diagnosis
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who had recently received a new diagnosis of unspecified convulsions (seizures). Although the resident's face sheet and MDS assessment reflected the new diagnosis, the care plan did not include seizures as a problem, nor did it outline goals or interventions related to seizure management. The resident, who had a severely impaired cognitive status as indicated by a BIMS score of 03, had experienced witnessed seizures and a subsequent hospital stay before returning to the facility. Despite these events, the care plan was not updated to address the new diagnosis. Interviews with facility staff, including the MDS Nurse, DON, ADM, and BOM, confirmed that the policy required care plans to be updated when new diagnoses were identified. However, the staff acknowledged that the care plan had not been revised to reflect the resident's seizure disorder. The facility's policy emphasized the importance of updating care plans to ensure all staff are informed and able to provide appropriate care, but this was not followed in this instance.
Failure to Maintain Sanitary and Accessible Emergency Eyewash Station in Kitchen
Penalty
Summary
The facility failed to maintain a safe, sanitary, and accessible emergency eyewash station in the kitchen. During multiple observations, the eyewash station was found with a roll of paper towels inside the basin, a visible white film or residue, and the protective eyewash covers were not properly positioned or capped. The area around the station was cluttered and blocked by various items including a trash can, brooms, a dustpan, a meal tray cart with soiled trays, a box of gloves, and rolls of trash bags, making the station inaccessible. Signage was present instructing staff to keep the area clear and to test the equipment weekly, but these instructions were not followed. Interviews with dietary staff revealed a lack of awareness about the existence and use of the emergency eyewash station, and no documented training was provided to staff regarding its use. The Dietary Manager (DM) stated that staff were responsible for cleaning their own areas and that the Maintenance Director was responsible for servicing the eyewash station, but there was no clear policy or documented training on the eyewash station. The inspection task sheet for the eyewash station included instructions for keeping the area clear and the covers in place, but these were not adhered to, and the DM was unsure how often inspections were performed. The Administrator confirmed there was no policy for the eyewash station and acknowledged the area was cluttered, which did not meet expectations for cleanliness and accessibility.
Failure to Update Care Plan for Dietary Change
Penalty
Summary
The facility failed to develop and implement a complete care plan that met the current needs of a resident, specifically regarding dietary interventions. The resident, an elderly female with severe cognitive impairment and multiple health conditions including malnutrition and dementia, had a physician's order for a vegetarian diet. However, the care plan did not reflect this dietary change, as it lacked a goal or intervention for a vegetarian diet. This oversight was identified during a review of the resident's care plan and physician orders. Interviews with facility staff revealed that the responsibility for updating the care plan fell to LVN F, who acknowledged receiving a request to update the resident's diet to vegetarian but failed to do so due to being occupied with other duties. The MDS coordinator confirmed that care plans should be updated when orders change, and the ADM emphasized the importance of timely updates to ensure residents' needs are met. The facility's policy on comprehensive person-centered care plans also supports the need for ongoing assessments and revisions as residents' conditions change.
Failure to Accommodate Resident's Vegetarian Diet
Penalty
Summary
The facility failed to provide food that accommodates a resident's dietary preferences, specifically a vegetarian diet, for one of the residents reviewed. The resident, an elderly female with severe cognitive impairment and multiple health issues, including malnutrition and dementia, was admitted to the facility with a physician's order for a vegetarian diet with puree texture and nectar thick consistency. Despite this, the resident received meat on her meal tray on multiple occasions, as noted in grievances filed by her responsible party (RP). The deficiency occurred due to a breakdown in the facility's process for ensuring residents receive the correct meals. The Director of Nursing (DON) stated that the facility's process involved dietary staff reviewing special instructions on meal tickets, charge nurses verifying the meal tickets, and CNAs delivering the trays. However, on the day in question, the charge nurses were occupied with other duties and did not verify the meal tray, leading to the resident receiving meat. The kitchen staff acknowledged the error, and the kitchen manager confirmed that the meal ticket had instructions for no meat, but the tray was not checked before delivery. Interviews with staff revealed that the oversight was due to multiple staff members being busy with other tasks, resulting in the failure to verify the meal tray. The resident's RP became upset upon discovering the error, leading to a confrontation with the facility staff. The facility's policy on tray service emphasizes the importance of accurate tray service and meeting residents' preferences, but the lack of a formal verification policy contributed to the deficiency.
Neglect Leads to Resident's Injury and Death
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a serious injury and subsequent death. A certified nursing assistant (CNA) observed signs of dizziness in a resident but did not report this change in condition to a nurse. Instead, the CNA proceeded to take the resident to the shower room. While the CNA's back was turned, the resident attempted to stand up unassisted, fell, and sustained a nondisplaced right inferior pubic ramus fracture and a right parietal scalp hematoma with an underlying acute traumatic subarachnoid hemorrhage. The resident was sent to the emergency room and later placed on hospice care, where she passed away. The resident involved was an elderly female with severe cognitive impairment, as indicated by a BIMS score of 3. She required partial/moderate assistance with showering and supervision or touching assistance with tub-shower transfers. Her care plan noted she was at risk for falls due to confusion, incontinence, and being unaware of safety needs. Despite these risks, the facility's fall risk evaluation categorized her as low risk for falls, and she had no recorded falls since admission until the incident. Interviews with facility staff revealed that CNAs were responsible for showering residents and were instructed never to turn their backs on residents during showers. However, the CNA involved did not adhere to this protocol and failed to report the resident's dizziness to a nurse, citing the absence of a nurse on duty at the time. The facility's Director of Nursing (DON) and other staff members confirmed that CNAs were expected to report any changes in a resident's condition immediately. The facility lacked documented evidence of training related to falls, abuse, neglect, and change in condition for the CNA involved.
Inadequate CNA Competency Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that a certified nursing assistant (CNA A) had the necessary competencies to provide safe care, resulting in a serious incident involving a resident. CNA A did not report signs of dizziness observed in a resident before taking her to the shower room. The resident, who had severe cognitive impairment and required assistance with showering, fell in the shower room after CNA A turned her back to grab supplies. This fall resulted in the resident sustaining a nondisplaced right inferior pubic ramus fracture, a right parietal scalp hematoma, and an acute traumatic subarachnoid hemorrhage. The resident was admitted to the hospital following the fall, where her condition deteriorated, leading to her being placed on hospice care. The resident eventually passed away due to the brain bleed caused by the fall. Interviews with other CNAs and licensed vocational nurses (LVNs) revealed that it was standard practice to never turn their back on a resident in the shower room and to have all shower supplies prepared beforehand. However, CNA A did not follow these protocols and failed to notify a nurse of the resident's change in condition, which was a critical oversight. The facility's documentation and interviews indicated a lack of specific training and protocols for CNAs regarding the notification of changes in a resident's condition. The facility's policies did not clearly outline the responsibilities of CNAs in such situations, contributing to the incident. Additionally, there was no evidence of recent training for CNA A related to falls, abuse, neglect, and change in condition, highlighting a gap in the facility's training and competency evaluation processes.
Failure to Timely Report Alleged Violations and Injuries
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, within the required timeframes. Specifically, the facility did not report Resident #1's fall, which resulted in a brain bleed and broken pubic bone, to the State Agency (SA) within the mandated two-hour window. The incident occurred when Resident #1 fell in the shower, and although the family was informed, the facility delayed notifying the SA until after the family reported the brain bleed discovered at the hospital. Similarly, the facility did not report Resident #2's injury of unknown source within the required timeframe. Resident #2 was found with a hematoma on the forehead, a skin tear, and a swollen wrist, which was later confirmed as fractured. The incident was unwitnessed, and the resident was sent to the hospital for evaluation. Despite the severity of the injuries, the facility failed to notify the SA within the two-hour requirement for injuries of unknown origin. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed a lack of awareness and adherence to the reporting guidelines. The DON admitted to not knowing the exact time of the observations and reports made by the staff, and the ADM was unaware that injuries of unknown origin required reporting within two hours. This lack of timely reporting could potentially affect the health and safety of the residents, as it delays the necessary investigations and interventions.
Failure to Serve Meals Simultaneously
Penalty
Summary
The facility failed to treat six residents with respect and dignity by not serving their lunch trays at the same time as their tablemates. This resulted in some residents having to wait for their meals while others at the same table were already eating. For instance, Resident #1 had to wait approximately 35 minutes after her tablemates received their food, which made her feel bad and neglected. Similarly, Resident #2 had to wait until his tablemate finished eating before receiving his lunch tray, and Resident #3 was observed trying to grab food from another resident's plate due to the delay in receiving her meal. The issue was exacerbated by ongoing construction in the main dining hall, which led to the use of an auxiliary dining hall with limited space. The food carts were delivered to Unit C at different times, causing delays in meal service. Staff interviews revealed that the food carts were not brought to the unit simultaneously, and the trays were not served according to the seating chart. This led to some residents feeling neglected and upset, as they had to wait for their food while others were eating. The facility's policy stated that all residents at one table should be served at the same time to ensure a dignified dining experience. However, this policy was not followed, leading to a lack of respect and dignity for the affected residents. Staff members, including CNAs, LVNs, and the Dietary Manager, acknowledged the issue and stated that the current system was problematic. The DON and Administrator also recognized the dignity problem and emphasized the importance of serving all residents at a table simultaneously to prevent feelings of neglect and ensure a positive dining experience for all residents.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
The facility failed to ensure that residents who were unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, the facility did not ensure that the fingernails of four residents were trimmed and cleaned. This deficiency was observed in residents with various medical conditions, including hemiplegia, hemiparesis, muscle weakness, type 2 diabetes mellitus, contractures, autistic disorder, seizures, chronic pain, and cognitive impairments. The residents were assessed to require extensive or total assistance with personal hygiene, yet their fingernails were found to be jagged and had blackish/brownish substances underneath them during observations and interviews conducted by surveyors. Resident #4, a male with hemiplegia and hemiparesis, was observed with jagged fingernails and blackish/brownish substances underneath them. Despite being assessed to require extensive assistance with personal hygiene, his nails were not properly maintained. Similarly, Resident #52, who had contractures and seizures, was found with jagged fingernails and blackish/brownish substances underneath them. This resident was assessed to require total dependence on one staff member for personal hygiene. Resident #73, who had type 2 diabetes mellitus and chronic pain, was also observed with jagged fingernails and blackish/brownish substances underneath them. This resident was assessed to be totally dependent on one staff member for personal hygiene. Lastly, Resident #109, who had muscle weakness and type 2 diabetes mellitus, was found with jagged fingernails and blackish/brownish substances underneath them. This resident required limited assistance with personal hygiene. Interviews with staff revealed inconsistencies in the responsibility for nail care, with some staff believing it was the responsibility of CNAs and others believing it was the responsibility of nurses, particularly for diabetic residents. The facility's policy on ADLs indicated that residents would be provided with care to maintain good grooming and personal hygiene, but this was not adhered to in these cases.
Failure to Support Resident Self-Determination
Penalty
Summary
The facility failed to promote and facilitate resident self-determination through support of resident choice for one resident reviewed for self-determination. The resident, who had multiple diagnoses including multiple sclerosis, anxiety disorder, type 2 diabetes, dysthymic disorder, major depressive disorder, unspecified dementia, and cauda equina syndrome, was denied the right to attend a group therapy activity by a CNA. The resident expressed a desire to attend the group therapy exercise but was told by the CNA that she could not because she was on hospice care, which caused the resident visible agitation and mental anguish. The resident's care plan indicated that she was very social, loved to be out in activities settings, and attended all special events. The care plan also specified that CNAs were to assist and escort the resident to activity functions. Despite this, the CNA did not facilitate the resident's participation in the group therapy activity. Other staff members, including another CNA and a Physical Therapy Assistant (PTA), confirmed that there was no policy preventing hospice residents from attending group therapy activities. The PTA later verified with the Director of Rehabilitation (DOR) that hospice residents were indeed allowed to join group therapy activities. Interviews with the Director of Nursing (DON) and the Administrator revealed that staff were expected to allow residents to attend therapy activities regardless of their hospice status. The DON acknowledged that the CNA should have inquired about the resident's eligibility to join the activity before denying her request. The Administrator also stated that CNAs should not be deciding which activities residents could attend and recognized that being denied participation could make the resident feel sad and upset. The facility's policy on Resident Rights emphasized the importance of treating all residents with kindness, respect, and dignity, and supporting their right to self-determination.
Improper Transfer Technique Leading to Resident Pain
Penalty
Summary
The facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents, specifically in the case of a resident who was improperly transferred from her bed to a wheelchair. The resident, who had multiple diagnoses including osteoarthritis, osteoporosis, muscle weakness, and difficulty walking, required extensive assistance with transfers. Despite this, a CNA did not use a gait belt during the transfer, causing the resident pain in her right arm between the elbow and wrist. The CNA admitted to not using the gait belt, which was a requirement for such transfers, and acknowledged the mistake during an interview. The resident's medical records indicated she required extensive assistance with one staff person for transfers and had a history of pain management. Observations and interviews revealed that the CNA used her hands to pull the resident by her arms, which was not a proper transfer technique. The resident expressed pain during and after the transfer, although no visible injuries such as redness or bruising were observed. Multiple staff members, including the Director of Nurses and other CNAs, confirmed that the use of a gait belt was mandatory for such transfers and that the improper technique used could potentially cause injuries. Interviews with various staff members, including the Director of Nurses, LVNs, and the Administrator, confirmed that the facility had protocols and training in place for proper transfer techniques, including the use of gait belts. However, the CNA involved did not follow these protocols, leading to the incident. The facility's policy on safe lifting and movement of residents emphasized the use of appropriate techniques and devices to ensure the safety and well-being of both staff and residents. The CNA was subsequently blocked from working at the facility by the agency that employed her.
Failure to Obtain Signed Hospice Order for Resident
Penalty
Summary
The facility failed to ensure that Resident #1's physician signed and dated the verbal order for hospice care. This deficiency was identified during a review of Resident #1's records, which revealed that the hospice care order was not signed by the attending physician. The resident, a female with multiple diagnoses including multiple sclerosis, anxiety disorder, type 2 diabetes, and dementia, was readmitted to the facility and required hospice services. However, the necessary documentation to confirm these services was missing from her chart, placing her at risk of receiving unconfirmed hospice care. During interviews, the Director of Nursing (DON) and the Registered Nurse Coordinator (RNC) acknowledged the absence of the signed hospice order in Resident #1's chart. The DON stated that the hospice order was eventually found and placed in the resident's chart, but it was initially missing. The RNC explained that the facility's policy required an order for hospice services to be in place, but the admitting nurse did not follow through with this requirement. The RNC also mentioned that the facility's electronic chart indicated the resident was on hospice, which may have led staff to assume the order was already in place. The facility's policy on medication orders and early identification of end-of-life procedures was reviewed, revealing that a current list of orders must be maintained in each resident's clinical record. Despite this policy, the facility failed to ensure that Resident #1's hospice order was signed and dated by the physician, leading to a deficiency in the resident's care documentation. Interviews with staff indicated a lack of clarity and adherence to the policy, contributing to the oversight in obtaining the necessary hospice order for Resident #1.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate was not five percent or greater, resulting in a medication error rate of 7%. This was based on two errors out of 32 opportunities, involving two residents. For Resident #15, the medication aide applied a Lidocaine 4% patch to the resident's lower back instead of the left hip as ordered. Despite the resident experiencing pain in the lower back, the order was not updated to reflect this change. The medication aide admitted to applying the patch to the lower back based on past practice rather than the current physician's order. This discrepancy was confirmed through interviews with the medication aide and a licensed vocational nurse, who emphasized the importance of following the physician's orders precisely and updating them as needed. For Resident #274, the facility failed to administer Linaclotide 290 mcg PO for constipation as ordered. The medication was not given on four consecutive days because it was out of stock, and the facility did not obtain approval to administer it due to its high cost. The medication aide and a registered nurse confirmed that the medication was not available and that an alternative treatment was sought. The facility's policy on medication administration, which includes verifying the right drug, dose, route, time, and documentation, was not followed in these instances, leading to the observed deficiencies.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 323 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Round Rock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Gabriel Rehabilitation And Care Center | 1.7 mi | ★★★★★ | 5 | 2 |
| Hearthstone Nursing And Rehabilitation | 2.6 mi | ★★★★★ | 7 | 0 |
| Park Valley Inn Health Center | 3 mi | ★★★★★ | 9 | 0 |
| Ignite Medical Resort Round Rock, Llc | 3.9 mi | ★★★★★ | 12 | 0 |
| Bel Air At Teravista | 3.9 mi | ★★★★★ | 4 | 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.