Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
TRINITY TERRACE
FORT WORTH, TX · 52 certified beds · Last Life Safety survey May 29, 2026
CMS Certification Number 675238 · first certified January 1994
Also on this campus
The same campus holds a state-licensed assisted living facility, with its own state record on the Assisted Living Index: Trinity Terrace Assisted Living & Memory Support (1600 Texas Street). Matched by the telephone number the two records share. The records are separate and are never added together.
Ownership
Operated by PACIFIC RETIREMENT SERVICES · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within TX
12 citations — more than 74% of the 1,177 certified nursing homes in TX. Compared within TX rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys in the window averaged 3. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens July 2027 — about 9 months from now. This facility’s last Life Safety survey was May 2026. Facilities in TX are typically surveyed 13–14 months after the last one (median 14), measured over 1,905 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 12 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 12 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in TX, and nationally. Surveyors differ markedly between states, so the TX figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 12 |
| Median facility in TX | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 8, 2024 | 2 |
| March 27, 2025 | 4 |
| May 29, 2026 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2026-05-29 |
| K-0379 | Have proper openings in smoke barrier doors. | 1 | 2026-05-29 |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | 1 | 2026-05-29 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2024-02-08 |
| K-0311 | Have an enclosure around a vertical opening shaft. | 1 | 2026-05-29 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2025-03-27 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2025-03-27 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2026-05-29 |
What the citations cover
- Smoke Deficiencies 7
- Emergency Preparedness Deficiencies 2
- Egress Deficiencies 2
- Gas, Vacuum, and Electrical Systems Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Emergency Preparedness Deficiencies | 2 |
| Egress Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 29, 2026 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has no plan of correction |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has no plan of correction |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Deficient, Provider has no plan of correction |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has no plan of correction |
| K-0379 | Have proper openings in smoke barrier doors. | Deficient, Provider has no plan of correction |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has no plan of correction |
March 27, 2025 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (May 9, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (April 29, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 25, 2025) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (April 15, 2025) |
February 8, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (February 9, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (February 15, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.