Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Trinity Terrace during CMS and state inspections, most recent first.
A resident prescribed Brimonidine Tartrate eye drops BID for glaucoma-related findings had multiple gaps where the medication was not available, yet staff documented it as administered on the MAR. The resident said he had gone several days without the eye drops, and staff interviews confirmed repeated ordering issues and that the medication was still missing from the cart during observation. The facility’s in-service stated that documenting a medication as given when it was not physically received is not permitted.
Unlocked Medication Cart Left Unattended: A medication cart was observed unlocked and unattended in a hallway, with its drawers facing outward while visitors and a housekeeper walked by. The MA stated she briefly stepped away and did not realize the cart was left open. RN and the ADON stated the cart must be locked whenever staff walk away, and facility policy required medication carts and supplies to be locked when not attended by authorized personnel.
Failure to perform hand hygiene between glove changes during toileting care. A CNA assisting a resident with stool present removed soiled gloves and put on a new pair without sanitizing or washing hands, while another CNA did sanitize after glove removal. The resident was dependent on toileting, had moderate cognitive impairment, and had a hx of UTI and incontinence-related UTI risk. The IP stated staff were expected to wash hands before care, between glove changes, and after care, and the facility policy stated gloves do not replace hand hygiene.
A medication aide failed to sanitize a reusable blood pressure cuff between uses on multiple residents, including one on Enhanced Barrier Precautions due to an open wound. This oversight was acknowledged by the aide, who was aware of the need to prevent cross-contamination. Staff interviews confirmed they were in-serviced on proper sanitization protocols, which are outlined in the facility's infection control policy.
The facility failed to comply with food service safety standards when a cook was observed without a hair restraint in the kitchen, risking food contamination. The cook admitted to forgetting the hairnet due to being overwhelmed by unprepared salads. The Nutrition Services Manager confirmed the requirement for hairnets, aligning with the facility's policy and the Federal Food Code.
Medication Documented as Given When Eye Drops Were Not Available
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate acquiring, receiving, dispensing, and administering of medications for one resident who was prescribed Brimonidine Tartrate Ophthalmic Solution 0.2% one drop in both eyes twice daily for open angle with borderline findings, low risk, bilateral. The resident’s record showed diagnoses including hypertension and renal insufficiency, and the MDS reflected a BIMS of 13, indicating intact cognition. The MAR and progress notes documented multiple periods when the eye drops were not available, yet doses were still charted as administered during those times. Record review showed the medication was not delivered to the facility during several intervals, including from 05/15/26 through 05/19/26, from 05/19/26 through 05/22/26, and from 05/25/26 through 05/27/26, while staff documented administration on the MAR. The resident stated he had not had one of his eye drops for several days and was waiting for the facility to obtain it. Staff interviews confirmed the medication had been ordered, reordered, and followed up on, but was still not present on the cart during observation on 05/29/26. The facility in-service stated that documenting a medication as administered when it was not physically received by the resident is unacceptable and not permitted.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and that only authorized personnel had access to the keys for medication cart #1. During an observation on 05/27/2026 at 3:24 P.M., the red panel on medication cart #1 was outwards, indicating the cart was unlocked. The cart was observed midway down the hallway with the drawers facing outward and unlocked, while three visitors and a housekeeper walked by the open cart. MA D was not in view of the cart at the time of the observation. During an interview on 05/27/2026 at 3:32 P.M., MA D stated she ran around the corner real quickly and did not know she left the cart open, and stated the medication cart was supposed to be locked so residents could not get into it. On 05/28/26 at 10:00 A.M., RN G stated the medication cart had to be locked before staff could walk away. On 05/29/26 at 11:19 A.M., the ADON stated that when staff step away from the medication cart, they should lock the cart, and that the cart needed to be secured for the residents' and visitors' safety. Facility policy stated that only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications were permitted to access medications, and that medication rooms, carts, and medication supplies were locked when not attended by authorized persons.
Failure to Perform Hand Hygiene Between Glove Changes During Toileting Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program when CNA A did not perform hand hygiene after removing soiled gloves and before putting on a new pair of gloves while providing toileting care for Resident #17. During the observation, CNA A and CNA B were assisting the resident with toileting before transferring him from bed to wheelchair for a shower. Both CNAs washed their hands before care, and CNA A wiped the resident’s bottom, which had stool present, then removed her soiled gloves and changed gloves without sanitizing or washing her hands. CNA B was observed to sanitize her hands after removing her soiled gloves before putting on new gloves, and both CNAs washed their hands after toileting care was completed. Resident #17 was an [AGE]-year-old male admitted with diagnoses of cancer, renal failure, and diabetes. His quarterly MDS indicated he was dependent on toileting and had a BIMS score of 08, showing moderate cognitive impairment. His care plan, revised on 3/30/2026, noted a history of UTI and risk for UTI due to incontinence. CNA B stated she noticed CNA A did not perform hand hygiene after removing her soiled gloves and whispered to her to wash her hands, but CNA A did not do so. CNA A stated she realized she did not sanitize her hands after removing the soiled gloves and said she got nervous and kept going. The Infection Preventionist stated staff were expected to wash hands before patient care, in between glove changes, and after providing resident care, and the facility’s hand hygiene policy stated to use alcohol-based hand rub after removing gloves and that gloves do not replace handwashing/hand hygiene.
Failure to Sanitize Blood Pressure Cuff Between Uses
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a medication aide (MA A) who did not sanitize a reusable blood pressure cuff between uses on five residents. During a medication administration observation, it was noted that MA A did not clean the blood pressure cuff between checks for Residents #11, #18, #19, #33, and #94. This oversight occurred despite MA A's acknowledgment that she was aware of the need to sanitize the cuff to prevent cross-contamination. Resident #94 was on Enhanced Barrier Precautions due to an open wound, highlighting the increased risk of infection transmission. Interviews with various staff members, including registered nurses and certified nursing assistants, revealed that they had been in-serviced on the importance of sanitizing equipment between resident uses. The Assistant Director of Nursing (ADON) confirmed that MA A had reported her failure to sanitize the cuff, prompting an in-service training session for all relevant staff. The facility's Infection Control Standard Precautions policy mandates that reusable equipment must be appropriately cleaned and disinfected before being used on another resident, a protocol that was not followed in this instance.
Failure to Wear Hair Restraint in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. On the morning of March 25, 2025, Cook I was seen in the kitchen without wearing a hair restraint, which is a requirement for all kitchen staff to prevent food contamination. Cook I admitted to forgetting to put on a hairnet due to being overwhelmed by the unprepared salads upon starting her shift. This oversight was acknowledged during an interview, where Cook I recognized the potential risk of hair falling into the food. The Nutrition Services Manager confirmed that all kitchen staff are required to wear hairnets upon entering the kitchen, with hairnets and beard nets available at each entrance. The facility's Uniform Dining Services policy, revised in November 2024, mandates that hair must be pulled up and contained in a hairnet. Additionally, the Federal Food Code 2022 specifies the necessity of wearing effective hair restraints to prevent contamination. The failure to comply with these standards could place residents at risk for food contamination and foodborne illness.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| James L. West Center For Dementia Care | 0.1 mi | ★★★★★ | 0 | 0 |
| The Stayton At Museum Way | 0.6 mi | ★★★★★ | 3 | 0 |
| Downtown Health And Rehabilitation Center | 0.7 mi | ★★★★★ | 12 | 0 |
| Arbor Lake Nursing & Rehabilitation, Llc | 0.9 mi | ★★★★★ | 1 | 0 |
| Fort Worth Transitional Care Center | 1 mi | ★★★★★ | 17 | 1 |
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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 August 2026) and official state health department websites.