Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Village during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple neurologic diagnoses required at least one-person assistance for bed mobility per MDS data, PT documentation, and staff reports, yet the comprehensive care plan and care guide continued to list the resident as independent with bed mobility, needing only verbal cues. Floor staff acknowledged they knew the care guide was inaccurate but did not report the discrepancy, while a nurse identified that the MDS nurse was responsible for updating care plans and the care guide. The MDS nurse confirmed that therapy and NAs had communicated the need for assistance and admitted the care plan and care guide should not have indicated independence.
A resident with severe cognitive impairment and multiple neurologic diagnoses required substantial assistance and verbal cues for bed mobility, but her care plan and care guide inaccurately listed her as independent with rolling in bed. During incontinence care, a CNA, who had been told the resident now needed two-person assist for transfers, rolled her away from himself using the bed pad while positioned across the bed. The resident continued rolling off the low bed onto the carpeted floor, landing face first and sustaining a forehead abrasion.
A wound care nurse failed to follow the facility’s hand hygiene policy while providing sacral wound care to a resident with an unstageable pressure ulcer. After cleansing the wound bed and surrounding area using appropriate PPE and initial hand hygiene steps, the nurse did not remove gloves, perform hand hygiene, and don clean gloves before cutting and applying alginate with silver dressing to the wound bed, despite policy requiring hand hygiene and glove changes when moving from a contaminated procedure to a clean one. Interviews with the IP, DON, and the nurse confirmed that this step was omitted and that the expectation was to follow the hand hygiene procedures during wound care.
A resident was struck twice by a nurse aide during incontinence care after becoming aggressive. The resident, who was cognitively impaired, became emotionally upset but had no physical injuries. The nurse aide was suspended and later terminated following an investigation.
A resident was struck twice by a nurse aide during incontinence care after becoming combative. Another nurse aide witnessed the abuse but did not immediately report it, allowing the abuse to continue. The resident was emotionally upset but not physically injured. The facility's policy on abuse reporting was not followed adequately.
Failure to Maintain Accurate Care Plan for Bed Mobility Assistance
Penalty
Summary
The facility failed to update and revise an individualized, person-centered comprehensive care plan to accurately reflect a resident's bed mobility needs. The resident, who had non-traumatic brain dysfunction, Alzheimer's disease, non-Alzheimer's dementia, seizure disorder, and severe cognitive impairment, was assessed as requiring substantial/maximal assistance with rolling in bed on a quarterly MDS. A Physical Therapy discharge summary recommended two-person assistance for transfers and gait, and a therapy note documented that the resident required partial/moderate assistance for rolling in bed. In an interview, the Physical Therapist stated the resident required moderate to maximum assistance of two staff members with everything and that, at discharge from therapy, the resident still required one-person assistance with bed mobility. Despite these findings, the resident's care plan, updated on 01/16/26, documented that the resident was independent with bed mobility, requiring only verbal cues and occasional hands-on prompting, and the care guide likewise listed rolling left and right as independent. A NA reported that staff on the floor knew the care guide information was incorrect but had not reported it to anyone, even though they were expected to check and follow the care guide each morning. A nurse stated the resident required assistance of one staff member for bed mobility and that the MDS nurse was responsible for altering care plans and updating the care guide. The MDS nurse acknowledged responsibility for care plans, confirmed that therapy and NAs had indicated the resident needed at least one-person assistance for bed mobility, and stated the care plan should not have indicated independence and should have been correctly reflected in both the care plan and care guide.
Resident Rolled Out of Bed During Incontinence Care Due to Improper Positioning and Assistance
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 out of bed and hitting the floor face first. The resident had diagnoses including non-traumatic brain dysfunction, Alzheimer’s disease, non-Alzheimer’s dementia, and seizure disorder, and a quarterly MDS documented severe cognitive impairment with a need for substantial to maximal assistance for rolling in bed. A physical therapy note indicated the resident required partial to moderate assistance for rolling, and the physical therapist later stated the resident required moderate to maximum assistance of two staff members with everything, including direction and verbal cues, and that at discharge from therapy the resident still required one-person assistance with bed mobility. Despite these documented needs, the resident’s care plan and care guide indicated she was independent with bed mobility (rolling left and right), requiring only verbal cues and occasional hands-on prompting, and listed her as independent for rolling left and right. On the morning of the incident, a nurse aide entered the resident’s room to provide incontinence care and dressing assistance. He reported that he informed the resident he was going to change her and roll her onto her side, then picked up the bed pad and pulled it upward, rolling her onto her left side and away from him. As her weight shifted, she continued rolling off the bed and onto the floor face first while he was positioned across the bed and unable to catch her in time. The resident was found lying face down on the carpeted floor next to the bed with an abrasion to the right side of her forehead. Staff interviews, including with the nurse aide, Nurse #1, the DON, and the Administrator, confirmed that the resident was cognitively impaired, required verbal cues and assistance with bed mobility, and that the aide had been informed earlier that morning that the resident required two-person assistance with transfers. They also confirmed that during the incident the aide rolled the resident away from himself using the bed pad rather than toward himself while providing incontinence care, which led to her rolling off the bed onto the floor.
Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
The deficiency involves a failure to follow the facility’s Hand Hygiene policy during wound care for Resident #57, who had an unstageable pressure ulcer to the sacrum with orders to cleanse the wound with normal saline, pat dry, apply alginate with silver, and cover with a dry dressing daily and as needed. The facility’s policy required hand hygiene before donning and after removing gloves, before and after handling clean or soiled dressings, and before moving from a contaminated body site or procedure to a clean one, and specified that glove use does not replace hand hygiene. During an observed wound care procedure, the Wound Care Nurse initially followed protocol by cleansing the overbed table, placing a barrier and supplies, doffing gloves, sanitizing hands, and donning clean gloves before cleaning the sacral wound bed. After cleaning the wound bed, the Wound Care Nurse doffed her gloves, sanitized her hands, donned clean gloves, and cleaned the outer wound area with normal saline–soaked gauze and patted the wound dry. However, she then proceeded to cut the alginate with silver dressing and place it on the wound bed without doffing her gloves, sanitizing her hands, and donning clean gloves between the dirty procedure (cleansing the wound and surrounding area) and the clean procedure (cutting and applying the dressing), contrary to the facility’s Hand Hygiene policy. Subsequent interviews with the Infection Preventionist, the Wound Care Nurse, the DON, and the Administrator confirmed that the nurse did not perform the required glove change and hand hygiene at that point in the procedure and that the expectation was for the policy to be followed during wound care.
Resident Abuse During Incontinence Care
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when a nurse aide (NA) struck a resident during incontinence care. The resident, who was cognitively impaired and had a history of physical and verbal behaviors, was struck twice on the shoulder by NA #1 after becoming aggressive. This incident resulted in the resident crying and being emotionally upset. The incident occurred when NA #1 and another nurse aide (NA #2) were providing incontinence care to the resident. The resident became aggressive, hitting and spitting at NA #1, who then struck the resident in response. Despite being told by NA #2 to stop, NA #1 continued the care and struck the resident again. NA #1 admitted to hitting the resident but did not believe her actions were abusive. The facility's investigation included interviews with the involved staff and the resident, who did not recall the incident. The resident was found to be emotionally upset but had no physical injuries. NA #1 was immediately suspended and later terminated following the investigation.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from further abuse when a nurse aide (NA #2) witnessed another nurse aide (NA #1) striking a resident during care and did not immediately report the incident to her supervisors. This resulted in NA #1 striking the resident a second time, causing the resident to cry. The incident occurred when the resident became combative during incontinence care, and NA #1 reacted by hitting the resident on the left shoulder and face. NA #2 intervened verbally but did not stop the care or report the incident immediately, allowing the abuse to continue. The resident involved had a history of aggressive behavior, including hitting and spitting on staff. During the incident, the resident became angry and combative, leading NA #1 to strike the resident twice in response to the resident's actions. NA #1 admitted to hitting the resident but did not believe her actions were abusive. The resident was emotionally upset following the interaction, although no physical injuries were observed. The facility's policy on abuse investigation and reporting was not followed adequately, as NA #2 did not stop the care or report the incident immediately. The Director of Nursing and the Administrator were informed of the incident, and an investigation was conducted. NA #1 was suspended and later terminated. The facility's failure to protect the resident from further abuse and the delay in reporting the incident were significant deficiencies in the care provided to the resident.
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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 Viewmont | 1 mi | ★★★★★ | 1 | 1 |
| The Greens At Hickory | 2.3 mi | ★★★★★ | 14 | 0 |
| Trinity Ridge | 4.9 mi | ★★★★★ | 1 | 0 |
| Conover Nursing And Rehabilitation Center | 6.2 mi | ★★★★★ | 1 | 0 |
| Hickory Falls Health And Rehabilitation | 7.6 mi | ★★★★★ | 0 | 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.