Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Trinity Glen during CMS and state inspections, most recent first.
A resident receiving aripiprazole 5 mg daily for depression continued on the same regimen despite a pharmacist’s MRR recommendation to consider tapering the antipsychotic and using an alternative depression treatment if appropriate. The Medical Director documented agreement with the recommendation and noted that the NP would follow up, but MARs showed ongoing daily administration with no taper attempts and no psychiatry referral. The Primary NP reported she was not responsible for psychiatric medication taper decisions and had not seen the recommendation, the Psychiatric NP stated she had never received a referral for the resident, and the ADON reported she had re-delivered the recommendation to the NP after noticing no action, resulting in no documented provider response to the pharmacist’s recommendation.
A resident with vascular dementia, left-sided paralysis, muscle weakness, and documented dependence for bed mobility was care planned and listed on the care guide as requiring a two-person assist for rolling and incontinence care, with use of a lift for transfers. During an early-morning incontinence care episode, a NA who usually worked on another hall provided care alone, rolling the resident onto the left side and having the resident hold a side chair with the right hand for support instead of obtaining the required second staff member. The chair reportedly moved, the resident lost balance, rolled off the bed onto the floor, and later complained of right knee pain, prompting hospital evaluation where imaging showed no fractures. Staff interviews and documentation confirmed the resident’s total dependence for rolling and the expectation for two-staff assistance, which was not followed at the time of the incident.
Failure to Act on Pharmacist Recommendation for Antipsychotic Taper
Penalty
Summary
The deficiency involves the facility’s failure to act on a pharmacist’s medication regimen review (MRR) recommendation for a resident receiving aripiprazole for depression. The resident was admitted with a diagnosis including depression and had a physician’s order for aripiprazole 5 mg daily. A pharmacist completed an MRR on 1/7/26, including an Abnormal Involuntary Movement Scale (AIMS) assessment that showed no involuntary movements and no new recommendations. On 2/2/26, the pharmacist’s subsequent MRR included a recommendation to consider tapering the resident off aripiprazole and introducing a different medication for depression if appropriate. The Medical Director documented agreement with this recommendation and wrote a note dated 2/24/26 indicating that the Nurse Practitioner would follow up regarding a taper or a psychiatry consult. Record review showed that despite the pharmacist’s recommendation and the Medical Director’s documented agreement, the resident continued to receive aripiprazole 5 mg daily with no evidence of dose taper attempts or a psychiatry referral. Medication administration records for February and March showed ongoing daily administration of aripiprazole per the original order, and the April record showed continued administration on the first two days of the month. The resident’s AIMS assessment on 2/24/26 again showed a score of zero, indicating no abnormal involuntary movements, but there was no provider documentation addressing the pharmacist’s recommendation, no documented clinical decision about whether to taper, and no initiation of psychiatric services. Interviews revealed confusion and breakdowns in responsibility for following up on the pharmacist’s recommendation. The Primary NP stated she was not responsible for antipsychotic taper follow-up and believed psychiatric issues were handled by the Psychiatric NP, and she reported she had never seen the 2/2/26 recommendation or been aware of a directive to follow up. The Psychiatric NP reported she did not know the resident and had never received a referral. The Medical Director recalled the recommendation and believed the NP would complete the follow-up but was unaware it had not occurred. The DON and ADON described a process in which pharmacy recommendations were emailed to the ADON, printed, and hand-delivered to providers, with the ADON stating she monitored recommendations and had re-delivered the 2/2/26 recommendation to the Primary NP after noticing no apparent action. Despite these processes, there was no documented provider response or action on the pharmacist’s recommendation for this resident’s aripiprazole therapy.
Failure to Follow Two-Person Assist Requirements During Incontinence Care Leading to Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision during incontinence care, resulting in a resident rolling off the bed and requiring hospital evaluation. The resident had vascular dementia, left-sided paralysis following a stroke, muscle weakness, and was care planned as a two-person assist for bed mobility and transfers, with use of a lift and extra-large sling. The care guide and MDS documented that the resident was dependent for rolling left and right, and therapy evaluations and IDT risk assessments confirmed she was unable to sit unsupported and was at moderate risk for falls. On the day of the incident, a nurse aide assigned to third shift, who usually worked on a different hall, provided incontinence care to the resident alone at approximately 6:00 a.m. The aide knew the resident was dependent for rolling but had previously cared for her alone by rolling her onto her left side and having her hold onto a side chair with her right hand for support. During this episode of care, the aide again rolled the resident onto her left side and relied on the side chair for support instead of obtaining the required second staff member. The aide reported that she believed the other aide on the hall was already assisting another resident and did not request help. While the resident was on her left side holding the chair, the chair apparently moved, causing the resident to lose balance and continue rolling off the left side of the bed onto the floor. The resident reported she did not hit her head but injured her right knee and was subsequently transported to the emergency department, where imaging showed no fractures. Nursing staff interviews confirmed that the resident was unable to support herself and required two staff for turning and incontinence care, and the DON stated that aides are responsible for following the care guides, which in this case specified two-person assistance that was not used at the time of the fall.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 248 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Winston-salem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Valley Center For Nursing And Rehabilitatio | 3.8 mi | ★★★★★ | 10 | 1 |
| Arbor Acres United Methodist Retirement Community | 4 mi | ★★★★★ | 2 | 0 |
| Brookridge Retirement Community | 4.8 mi | ★★★★★ | 1 | 0 |
| The Oaks | 5.4 mi | ★★★★★ | 11 | 0 |
| Silas Creek Rehabilitation Center | 5.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Trinity Glen.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.