All citations for Trinity Manor

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Trinity Manor

Last standard health inspection on record

January 23, 2025

Showing 1 to 25 of 32 citations

Immediate jeopardy to resident health or safety
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Isolated (one or a few residents). CMS level J.
Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of July 15, 2024. Found during a complaint inspection.
Past non-compliance: already corrected by the time of the inspection (July 3, 2024).
Immediate jeopardy to resident health or safety
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Isolated (one or a few residents). CMS level J.
Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of February 8, 2024. Found during a complaint inspection.
Past non-compliance: already corrected by the time of the inspection (February 5, 2024).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Widespread (many residents). CMS level F.
Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of January 23, 2025. Found during a standard inspection and a complaint inspection.
The home gave a date the problem would be corrected (February 28, 2025).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
Widespread (many residents). CMS level F.
Health citation F-0880, Infection Control Deficiencies. Inspection of January 23, 2025. Found during a standard inspection and a complaint inspection.
The home gave a date the problem would be corrected (February 28, 2025).
No harm, with potential for more than minimal harm
Conduct risk assessment and an All-Hazards approach.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0006, Emergency Preparedness Deficiencies. Inspection of January 23, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 15, 2025).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0353, Smoke Deficiencies. Inspection of January 23, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 15, 2025).
No harm, with potential for more than minimal harm
Have simulated fire drills held at unexpected times.
Widespread (many residents). CMS level F.
Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of January 23, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (March 3, 2025).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Widespread (many residents). CMS level F.
Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of February 9, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 28, 2023).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0353, Smoke Deficiencies. Inspection of February 9, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (March 29, 2023).
No harm, with potential for more than minimal harm
Have simulated fire drills held at unexpected times.
Widespread (many residents). CMS level F.
Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of February 9, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (March 29, 2023).
No harm, with potential for more than minimal harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Widespread (many residents). CMS level F.
Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of February 9, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (March 29, 2023).
No harm, with potential for more than minimal harm
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Widespread (many residents). CMS level F.
Health citation F-0801, Nutrition and Dietary Deficiencies. Inspection of July 15, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (August 24, 2021).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Widespread (many residents). CMS level F.
Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of July 15, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (August 24, 2021).
No harm, with potential for more than minimal harm
Have approved installation, maintenance and testing program for fire alarm systems.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0345, Smoke Deficiencies. Inspection of January 23, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 15, 2025).
No harm, with potential for more than minimal harm
Properly select, install, inspect, or maintain portable fire extinguishes.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0355, Smoke Deficiencies. Inspection of January 23, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 20, 2025).
No harm, with potential for more than minimal harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0372, Smoke Deficiencies. Inspection of January 23, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 15, 2025).
No harm, with potential for more than minimal harm
Have properly installed electrical wiring and gas equipment.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0511, Services Deficiencies. Inspection of January 23, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 20, 2025).
No harm, with potential for more than minimal harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of January 23, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (February 20, 2025).
No harm, with potential for more than minimal harm
Have generator or other power source capable of supplying service within 10 seconds.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of January 23, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (March 3, 2025).
No harm, with potential for more than minimal harm
Have properly installed electrical wiring and gas equipment.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0511, Services Deficiencies. Inspection of February 9, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (March 29, 2023).
No harm, with potential for more than minimal harm
Have properly installed hallway dispensers for alcohol-based hand rub.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0325, Smoke Deficiencies. Inspection of July 15, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (August 26, 2021).
No harm, with potential for more than minimal harm
Ensure that residents are free from significant medication errors.
Isolated (one or a few residents). CMS level D.
Health citation F-0760, Pharmacy Service Deficiencies. Inspection of January 23, 2025. Found during a standard inspection and a complaint inspection.
The home gave a date the problem would be corrected (February 28, 2025).
No harm, with potential for more than minimal harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Isolated (one or a few residents). CMS level D.
Health citation F-0623, Resident Rights Deficiencies. Inspection of February 9, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 28, 2023).
No harm, with potential for more than minimal harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Isolated (one or a few residents). CMS level D.
Health citation F-0757, Pharmacy Service Deficiencies. Inspection of February 9, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (February 28, 2023).
No harm, with potential for more than minimal harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Isolated (one or a few residents). CMS level D.
Fire safety citation K-0321, Smoke Deficiencies. Inspection of February 9, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (March 29, 2023).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.