Trinity Ridge

In the surveyor’s words

From the most serious findings on record at Trinity Ridge, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF690Jun 18, 2026

  Based on observations, record review, staff and resident interviews, the facility failed to keep a urinary catheter collection bag from lying on the floor for 1 of 1 resident reviewed for indwelling urinary catheters (Resident #5). The findings included:Resident #5 was admitted to the facility on [DATE] with diagnoses that included overactive bladder, hydronephrosis (the swelling of one or both kidneys caused by a buildup of urine), and bladder-neck (the base of the bladder) obstruction.Resident #5's physician orders revealed a physician order dated 03/26/26 for a urethral catheter, due to urinary retention related to hydronephrosis, ensure tubing is patent and catheter is in a privacy bag. […]

• No harm, potential for more than minimal, isolatedF641Mar 27, 2025

  Based on record review and staff interviews, the facility failed to accurately code a Medicare 5-day Minimum Data Set assessment for the use of antipsychotics for 1 of 5 residents reviewed for unnecessary medications (Resident #87). The findings included: Resident #87 was initially admitted to the facility on [DATE] with diagnoses that included dementia with behaviors and cognitive communication deficit. Resident #87 subsequently readmitted to the facility on [DATE] after a brief hospitalization . Review of Resident #87's Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed he was not receiving antipsychotic medications. Review of Resident #87's physician orders revealed an order dated 03/07/25 for Seroquel Oral tablet (antipsychotic medication) 25 milligrams (mg). […]

• No harm, potential for more than minimal, isolatedF759Mar 27, 2025

  Based on observations, record reviews, manufacturer's instructions, and staff and Consultant Pharmacist interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 28 opportunities, resulting in a medication error rate of 7.14% for 1 of 5 residents observed during the medication administration (Residents #25). The findings included: The manufacturer's instructions for prefilled Lantus insulin pen indicated that priming the insulin pen each time was an important step to ensure there were no air bubbles in the insulin and the full dose of insulin was given. Priming the insulin pen: 1. Dial up 2 units: turn the dose selector dial to 2 units, 2. […]

• No harm, potential for more than minimal, isolatedF880Mar 27, 2025

  Based on observations, record reviews and staff interviews, the facility failed to follow their Hand Hygiene policy and procedure when the Director of Nursing did not perform hand hygiene after removing gloves and donning a clean pair of gloves while providing wound care to Resident #71 and Nurse #2 did not perform hand hygiene after removing gloves and donning a clean pair of gloves while providing wound care to Resident #62 for 2 of 3 staff members observed for infection control practices (Director of Nursing and Nurse #2). The findings included: A review of the facility's Hand Hygiene policy and procedure last revised 10/12/23 revealed in part: Hand Hygiene: Policy: Practicing hand hygiene is a simple yet effective way to prevent infections. […]

• No harm, potential for more than minimal, isolatedF550Nov 29, 2023

  Based on observations, record review, and staff interview the facility failed to maintain the dignity of a cognitively impaired resident (Resident #43) when a Nurse Aide made an inappropriate sexual comment about the resident's son. A reasonable person would not want another person making inappropriate sexual comments about their family members. This was for 1 of 1 resident reviewed for dignity and respect. The findings included: Resident #43 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia with behaviors, depression, and insomnia. A review of Resident #43's annual Minimum Data Set assessment dated [DATE] revealed resident was severely impaired with no psychosis, behaviors, rejection of care, or instances of wandering. […]