TRINITY CARE CENTER Nursing Home


TRINITY CARE CENTER (CCN: 675546) is a For profit - Limited Liability company facility located in ROUND ROCK, TX (78664). The facility has an overall rating of 4/5, health inspection rating of 4/5, and a staffing rating of 1/5. It offers 179 certified beds and maintains an average of 123. residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 2.91449 total hours per resident per day. It has been certified since December 1, 1995 and the last listed health inspection was on June 9, 2022, The facility is located in Williamson county and provides senior and nursing home care.

TRINITY CARE CENTER Summary


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Provider Name: TRINITY CARE CENTER

Address: 1000 E MAIN ST, ROUND ROCK, TX 78664

Phone: (512) 634-3000

County: Williamson (970)

Ownership Type: For profit - Limited Liability company

Certified Beds: 179

Average Residents Per Day: 123. ()

Provider Type: Medicare and Medicaid, Resides in Hospital: No

Legal Business Name: CARADAY TRINITY LLC

First Approved Date: December 1, 1995

Affiliated Entity: CARADAY HEALTHCARE (103)

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 4 ()

Health Inspection Rating: 4 ()

QM Rating: 5 ()

Long Stay QM Rating: 5 ()

Short Stay QM Rating: 5 ()

Staffing Rating: 1 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 1.87025, LPN Staff Hours Per Day: 0.8753, RN Staff Hours Per Day: 0.1688, Licensed Staff Hours Per Day: 1.0442

Total Nurse Staff Hours Per Day, per resident: 2.91449

Weekend Nurse Staff Hours: 2.73581, Weekend RN Staff Hours: 0.1110

PT Staff Hours Per Day, per resident: 0.0347

Nurse Staff Turnover: 69.6, Nurse Turnover Note:

RN Turnover: 57.1, RN Turnover Note:

Admin Left Number: 0, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 2.0545, Case Mix LPN Hours Per Day: 0.7994, Case Mix RN Hours Per Day: 0.4251

Adjusted Nurse Aide Hours Per Day, per resident: 1.85450, Adjusted LPN Hours Per Day: 0.8080, Adjusted RN Hours Per Day: 0.1496

Total Adjusted Nurse Hours Per Day, per resident: 2.80153

Adjusted Weekend Nurse Hours Per Day, per resident: 2.62977

Health Survey Dates and Scores: Cycle 1: 2022-06-09 (Score: 52), Cycle 2: 2019-10-23 (Score: 12), Cycle 3: 2018-11-07 (Score: 16)

Total Weighted Health Score: 32.667

Reported Incidents: 1, Substantiated Complaints: 2

Infection Control Citations: 1

Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 982.51, Payment Denials Number: 0, Total Penalties Number: 1

Location and GPS: 1000 E MAIN ST,ROUND ROCK,TX,78664 (30.5115, -97.668)

Process Date: 2024-03-01


Health Inspection Citations Details

Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-03-30

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-04-15

Citation on 2022-06-09

Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-01

Citation on 2022-06-09

Type: Health, Deficiency: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-01

Citation on 2022-06-09

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-01

Citation on 2022-06-09

Type: Health, Deficiency: Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-01

Citation on 2022-06-09

Type: Health, Deficiency: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-01

Citation on 2022-06-09

Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-01

Citation on 2022-05-19

Type: Health, Deficiency: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-06-03

Citation on 2019-10-23

Type: Health, Deficiency: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-11-14

Citation on 2021-10-28

Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-11-19

Citation on 2021-10-28

Type: Health, Deficiency: Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-11-19

Citation on 2021-10-28

Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-10-29

Citation on 2018-11-07

Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-11-08


Fire Safety Citations Details

Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2022-07-22

Type: Fire Safety, Tag: 0344, Version: New

Description: Have an alternate power supply for its alarm system.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-08-29

Citation on 2022-07-22

Type: Fire Safety, Tag: 0521, Version: New

Description: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-08-29

Citation on 2019-10-22

Type: Fire Safety, Tag: 0020, Version: New

Description: Establish policies and procedures including evacuation.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-11-14

Citation on 2019-10-22

Type: Fire Safety, Tag: 0039, Version: New

Description: Conduct testing and exercise requirements.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-11-14

Citation on 2019-10-22

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-11-14

Citation on 2019-10-22

Type: Fire Safety, Tag: 0521, Version: New

Description: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has no plan of correction on

Citation on 2018-11-08

Type: Fire Safety, Tag: 0037, Version: New

Description: Establish staff and initial training requirements.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-12-24

Citation on 2018-11-08

Type: Fire Safety, Tag: 0039, Version: New

Description: Conduct testing and exercise requirements.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-12-24

Citation on 2018-11-08

Type: Fire Safety, Tag: 0324, Version: New

Description: Provide properly protected cooking facilities.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-12-17

Citation on 2018-11-08

Type: Fire Safety, Tag: 0344, Version: New

Description: Have an alternate power supply for its alarm system.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-12-17

Citation on 2018-11-08

Type: Fire Safety, Tag: 0521, Version: New

Description: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-12-24

Citation on 2018-11-08

Type: Fire Safety, Tag: 0741, Version: New

Description: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-12-10