Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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 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.
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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How nearby facilities compare on the same public inspection record.
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| 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 | — | 1 | 0 |
| San Rafael Nursing And Rehabiliation | 4 mi | — | 8 | 1 |
| Avir At Corpus Christi | 4.2 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.