Above average — CMS composite of the measures below.
The next survey window likely opens around May 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 Ridge during CMS and state inspections, most recent first.
A resident with an indwelling urinary catheter, ordered for urinary retention related to hydronephrosis, was observed in bed with the catheter collection bag lying flat on the floor beside the bed and containing urine. The resident said an aide had helped her back to bed after breakfast, and one aide confirmed she assisted the resident but forgot to hang the bag from the bed frame as she normally would. The DON and Administrator stated catheter bags were expected to be kept off the floor.
A facility failed to accurately code a Medicare 5-day MDS assessment for a resident's use of antipsychotic medication. The resident, with dementia and cognitive deficits, was receiving Seroquel as per physician orders, but the MDS assessment incorrectly indicated no antipsychotic use. Staff interviews revealed the MDS nurse was aware of the medication but miscoded it, and the DON confirmed the assessment should have reflected the resident's medication regimen.
A medication error rate of 7.14% was identified in an LTC facility due to improper use of a Lantus insulin pen. A nurse failed to prime the pen before administering two doses to a resident with diabetes, contrary to the manufacturer's instructions. The error was confirmed by a Consultant Pharmacist, who emphasized the importance of priming to ensure correct dosage delivery.
The facility failed to follow its Hand Hygiene policy during wound care for two residents. The DON and a nurse did not sanitize their hands between glove changes while treating pressure ulcers, breaching infection control practices.
Catheter Bag Left on Floor Beside Bed
Penalty
Summary
Failure to provide appropriate catheter care occurred for a resident with an indwelling urinary catheter. The resident was admitted with diagnoses including overactive bladder, hydronephrosis, and bladder-neck obstruction, and the physician ordered a urethral catheter for urinary retention related to hydronephrosis, with instructions to ensure the tubing was patent and the catheter was in a privacy bag. The resident’s assessment identified the resident as cognitively intact and coded the resident as having an indwelling catheter, and the care plan included interventions to position the catheter bag and tubing below the level of the bladder. During an observation, the resident was in bed with visitors present, and the urinary catheter collection bag was lying flat on the floor beside the bed with urine in the bag. The resident stated a nurse aide had assisted her back to bed after breakfast and that she had not touched the catheter bag. One nurse aide stated she had not assisted the resident, while another nurse aide confirmed she assisted the resident back to bed and stated she normally hangs catheter bags from the bed frame when residents are returned to bed, but acknowledged she must have forgotten to do so in this instance. The DON and Administrator both stated the facility expected catheter bags to be kept off the floor and hung from the bed frame when a resident was in bed.
Inaccurate MDS Coding for Antipsychotic Use
Penalty
Summary
The facility failed to accurately code a Medicare 5-day Minimum Data Set (MDS) assessment for a resident regarding the use of antipsychotic medications. The resident, who had been admitted with diagnoses including dementia with behaviors and cognitive communication deficit, was readmitted to the facility after a brief hospitalization. Upon review, it was found that the resident's MDS assessment incorrectly indicated that the resident was not receiving antipsychotic medications, despite having a physician's order for Seroquel, an antipsychotic medication, which was being administered as per the medication administration record. Interviews with facility staff revealed that the MDS nurse responsible for completing the assessment was aware of the resident's Seroquel prescription but had miscoded the information in error. The Director of Nursing confirmed that the resident returned to the facility with a new order for Seroquel and acknowledged that the MDS assessment should have accurately reflected the resident's current medication regimen. The facility administrator expressed the expectation that MDS assessments accurately represent residents' care needs, including their medication use.
Medication Error Due to Improper Insulin Pen Use
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by 2 medication errors out of 28 opportunities, resulting in a 7.14% error rate. This deficiency was observed during the administration of medication to one resident. Specifically, the error involved the improper administration of Lantus insulin using a prefilled insulin pen. The manufacturer's instructions for the insulin pen require priming before each injection to remove air bubbles and ensure the correct dosage is delivered. However, Nurse #1 did not prime the insulin pen before administering two separate doses of insulin to the resident. The resident involved had a diagnosis of diabetes mellitus and was prescribed 85 units of Lantus insulin daily. During the observation, Nurse #1 prepared the insulin pen for injection by setting the dose selector to 30 units and then to 55 units for the second injection, as the total dose exceeded the pen's capacity for a single injection. Despite attending skills training that included instructions on using insulin pens, Nurse #1 failed to follow the priming procedure. The Consultant Pharmacist confirmed the importance of priming to ensure the correct dosage is administered, as air bubbles can prevent the full dose from being delivered.
Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
The facility failed to adhere to its Hand Hygiene policy and procedure during wound care for two residents. The Director of Nursing (DON) did not perform hand hygiene after removing gloves and before donning a new pair while providing wound care to a resident with a stage 3 pressure ulcer on the coccyx. The DON washed her hands initially, donned gloves and a gown, and proceeded with the wound care. However, after removing the gloves, she did not sanitize her hands before putting on a new pair of gloves, which is a breach of the facility's hand hygiene protocol. Similarly, Nurse #2, while providing wound care to another resident with a stage 4 pressure ulcer on the right foot, also failed to perform hand hygiene between glove changes. After removing the old dressing and doffing her gloves, Nurse #2 did not sanitize her hands before donning a new pair of gloves to continue the wound care. This pattern repeated during the care of the resident's sacral pressure ulcers, where Nurse #2 again did not sanitize her hands between glove changes. The DON, who was assisting, also did not ensure compliance with the hand hygiene protocol during these procedures.
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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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Nursing homes near Hickory
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Greens At Hickory | 4.3 mi | ★★★★★ | 14 | 0 |
| The Greens At Viewmont | 4.4 mi | ★★★★★ | 1 | 1 |
| Trinity Village | 4.9 mi | ★★★★★ | 3 | 0 |
| Carolina Rehab Center Of Burke | 6.4 mi | ★★★★★ | 4 | 1 |
| Conover Nursing And Rehabilitation Center | 7.3 mi | ★★★★★ | 1 | 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 July 2026) and official state health department websites.