Cycle 1
Health 2026-01-22 · Fire 2024-10-17
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Trinity, NC
The Graybrier Nursing and Retirement Center
3-star overall rating with 4-star inspections with $8,512 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
116 Lane Drive, Trinity, NC
(336) 431-8888
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
128
Certified beds
Average residents
103
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-11-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.56
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.19
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.93
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
4.63
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,536
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9969
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.86
Performance 19.18% · Measure score 4.86 · Achievement 4.86 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.34
Baseline 6.85% · Performance 6.24% · Measure score 5.34 · Achievement 5.34 · Improvement 2.79
Total nurse turnover
0
Performance 64.02% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
7.34
Baseline 4.54 hours · Performance 5.17 hours · Measure score 7.34 · Achievement 7.34 · Improvement 4.55
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.77% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 14.81% · Lower 95% interval 8.24% |
| Discharge to community | 47.66% |
50.57%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 44.19% · Lower 95% interval 35.95% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.11% |
95.27%
2.8 pts better
|
Numerator 52 · Denominator 53 |
| Falls with major injury | 1.89% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 53 |
| Discharge self-care score | 28.13% |
53.69%
25.6 pts worse
|
Numerator 9 · Denominator 32 |
| Discharge mobility score | 25% |
50.94%
25.9 pts worse
|
Numerator 8 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 11.32% |
2.29%
9 pts worse
|
Numerator 6 · Denominator 53 · Adjusted rate 9.32% |
| Healthcare-associated infections requiring hospitalization | 6.24% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 2.63% · Lower 95% interval 2.62% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 114 |
| Staff flu vaccination coverage | 50.88% |
42%
8.9 pts better
|
Numerator 58 · Denominator 114 |
| Discharge function score | 28.13% |
56.45%
28.3 pts worse
|
Numerator 9 · Denominator 32 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 33 · Denominator 33 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 13.79% |
25.2%
11.4 pts worse
|
Numerator 4 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.4 |
1.8
1.6 pts worse
|
1.9
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 2.9 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.8
0.5 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.5%
8.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.6%
1.7 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 1.1% · Q3 1.1% · Q4 1.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.4% |
4.8%
3.6 pts worse
|
11.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 7.8% · Q3 5.1% · Q4 11.6% · 4Q avg 8.4% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
7.2%
1.2 pts better
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 6.8% · Q3 2.7% · Q4 6.4% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.5% |
21.6%
2.1 pts better
|
19.6%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 18.9% · Q3 20.3% · Q4 19.0% · 4Q avg 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.0% |
15.0%
2 pts worse
|
16.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 18.0% · Q3 18.2% · Q4 13.6% · 4Q avg 17.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.9% |
21.5%
0.6 pts better
|
16.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 26.3% · Q3 16.9% · Q4 20.1% · 4Q avg 20.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.4% |
16.8%
0.6 pts worse
|
14.9%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 21.7% · Q3 16.2% · Q4 18.1% · 4Q avg 17.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 0.8% · Q4 0.6% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.8% |
2.6%
2.2 pts worse
|
1.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.1% · Q3 8.0% · Q4 7.4% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.8% |
21.2%
10.6 pts worse
|
19.8%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.1% · Q2 31.8% · Q3 18.5% · Q4 41.4% · 4Q avg 31.8% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
6.0%
0.6 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 5.8% · Q3 6.5% · Q4 5.8% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
79.9%
18.8 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 99.0% · Q3 98.9% · Q4 97.9% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.8% |
13.2%
1.4 pts better
|
12.0%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 13.7% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.1% |
78.1%
20 pts better
|
79.7%
18.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 37.5% |
22.9%
14.6 pts worse
|
23.9%
13.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 37.5% · Observed 39.2% · Expected 24.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-17 · Fire 2023-06-01
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-06-01 · Fire 2022-01-06
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-10-17
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-10-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-10-17
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2025-01-03
D · Potential for more than minimal harm
2023-06-01
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-01
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-01
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-14
D · Potential for more than minimal harm
2022-01-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-03-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-02-06
D · Potential for more than minimal harm
2024-10-17
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-06-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-18
G · Actual harm
2024-01-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-20
D · Potential for more than minimal harm
2023-06-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-14
D · Potential for more than minimal harm
2023-06-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-06-01
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-06-15
Penalties and ownership
What sits behind the stars
$8,512
2024-01-19
Fine
Fine · fine $8,512
Fine
Ownership
Lennon, Daniel
5% Or Greater Direct Ownership Interest · Individual
Lennon, Rudolph
5% Or Greater Direct Ownership Interest · Individual
Bennett, Richard
5% Or Greater Direct Ownership Interest · Individual
Canyon Management Consultants, Inc
Operational/Managerial Control · Organization
Harvey Linn Wilfong Trust U/W Fbo Trudy Wilfong
5% Or Greater Direct Ownership Interest · Organization
Lennon, Daniel
Corporate Officer · Individual
Lennon, Rudolph
Corporate Officer · Individual
Walker, Suzette
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Westwood Health and Rehabilitation
Archdale, NC
4-star overall rating with 3-star inspections with $15,642 in total fines with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Westchester Manor at Providence Place
High Point, NC
3-star overall rating with 3-star inspections with $8,018 in total fines with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Magnolia Gardens Center for Nursing and Rehabilita
Thomasville, NC
2-star overall rating with 2-star inspections with $16,153 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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