Trinity Terrace

Inspection findings

1. May 29, 2026 Health · 9 findings
   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jul 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Jun 26, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 10, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     CMS fire safety

   • Not serious Scope/severity E

     K0311 Smoke Deficiencies

     Have an enclosure around a vertical opening shaft.

     CMS fire safety

   • Not serious Scope/severity F

     K0342 Smoke Deficiencies

     Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

     CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     CMS fire safety

   • Not serious Scope/severity F

     K0379 Smoke Deficiencies

     Have proper openings in smoke barrier doors.

     CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     CMS fire safety

2. Mar 27, 2025 Fire Safety · 6 findings
   • Not serious Scope/severity F

     E0037 Emergency Preparedness Deficiencies

     Establish staff and initial training requirements.

     Corrected May 9, 2025 · CMS fire safety

   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Apr 29, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Apr 21, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 21, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Apr 25, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected Apr 15, 2025 · CMS fire safety

3. Feb 8, 2024 Health · 5 findings
   • Not serious Scope/severity E

     F0565 Resident Rights Deficiencies

     Honor the resident's right to organize and participate in resident/family groups in the facility.

     Corrected Feb 16, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Feb 27, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Feb 27, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Feb 9, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Feb 15, 2024 · CMS fire safety

4. Dec 7, 2023 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jan 8, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Jan 8, 2024 · CMS health inspection

Owners and managers (as published by CMS)

• AUSTIN, JAMES — corporate director, NOT APPLICABLE, since 12/18/2001
• BARR, ALAN — corporate director, NOT APPLICABLE, since 09/22/1998
• COULTER, BRIAN — corporate director, NOT APPLICABLE, since 10/01/2021
• FERNANDEZ, ROBERT — corporate director, NOT APPLICABLE, since 10/01/2014
• HYATT, MIKE — corporate director, NOT APPLICABLE, since 09/27/2010
• MCMAHON, MICHAEL — corporate director, NOT APPLICABLE, since 05/25/2011
• MILLS, DON — corporate officer, NOT APPLICABLE, since 09/23/2003
• SHOLTY, ERIC — corporate officer, NOT APPLICABLE, since 05/27/2018
• SMITH, GRETCHEN — corporate director, NOT APPLICABLE, since 09/27/2010
• STEMPEL, JUDY — corporate director, NOT APPLICABLE, since 10/01/2019
• TAFT, ANDY — corporate director, NOT APPLICABLE, since 10/01/2014
• THOMAS, MICHAEL — w-2 managing employee, NOT APPLICABLE, since 01/07/2019
• TRAVIS, KARL — corporate director, NOT APPLICABLE, since 12/18/2007
• VOGEL, CARLELA — corporate director, NOT APPLICABLE, since 03/28/2006
• WHITTON, JAMES — corporate director, NOT APPLICABLE, since 12/18/2001
• WILSON, DOUG — corporate director, NOT APPLICABLE, since 09/27/2010
• YOUNG, BRIAN — corporate director, NOT APPLICABLE, since 07/01/2021
• PACIFIC RETIREMENT SERVICES INC — operational/managerial control, NOT APPLICABLE, since 11/01/1995
• US BANK NATIONAL ASSOCIATION — 5% or greater security interest, NOT APPLICABLE, since 12/29/2011