Cycle 1
Health 2025-01-24 · Fire 2023-08-31
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Winston-Salem, NC
Trinity Glen
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
849 Waterworks Road, Winston-Salem, NC
(336) 595-2166
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
117
Certified beds
Average residents
105
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lutheran Services Carolinas
Operator or chain grouping
Approved since
1973-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.57
Registered nurse staffing
LPN hours / resident day
0.73
Licensed practical nurse staffing
Aide hours / resident day
3.42
Nurse aide staffing
Weekend hours
4.31
Weekend nurse staffing
RN turnover
27%
Annual RN turnover
Total nurse turnover
40%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.8
0.9 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.5% |
91.5%
2 pts worse
|
93.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.0% |
94.1%
2.9 pts better
|
95.5%
1.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
3.6%
1.2 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.8%
4.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 8.4% |
7.2%
1.2 pts worse
|
5.4%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.6% |
21.6%
2 pts better
|
19.6%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 15.4% |
15.0%
0.4 pts worse
|
16.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.3% |
0.0%
0.3 pts worse
|
0.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 30.0% |
21.5%
8.5 pts worse
|
16.3%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.4% |
16.8%
4.6 pts worse
|
14.9%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
0.9%
1.5 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
2.6%
1.6 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.0% |
21.2%
8.8 pts worse
|
19.8%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
6.0%
0.1 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.0% |
79.9%
14.1 pts better
|
81.7%
12.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.5%
0.4 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.6% |
78.1%
3.5 pts better
|
79.7%
1.9 pts better
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-31 · Fire 2022-03-30
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-03-30 · Fire 2019-12-05
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-08-31
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 2023-12-27
D · Potential for more than minimal harm
2023-08-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-27
D · Potential for more than minimal harm
2023-08-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-27
D · Potential for more than minimal harm
2019-12-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2020-01-17
Inspection history
Recent health citations
F · Potential for more than minimal harm
2022-03-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-04-27
E · Potential for more than minimal harm
2022-03-30
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-04-27
D · Potential for more than minimal harm
2022-03-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-04-27
D · Potential for more than minimal harm
2022-03-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-04-27
D · Potential for more than minimal harm
2022-03-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-04-27
D · Potential for more than minimal harm
2022-03-30
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 2022-04-27
Penalties and ownership
What sits behind the stars
Ownership
Lutheran Services For The Aging, Inc.
5% Or Greater Direct Ownership Interest · Organization
Goins, Ted
Operational/Managerial Control · Individual
Herman, Christopher
Operational/Managerial Control · Individual
Lsa Management, Inc.
Operational/Managerial Control · Organization
Lutheran Home Winston Salem Property Inc.
Operational/Managerial Control · Organization
Maddry, Karen
Corporate Officer · Individual
Nickerson, Kirby
Operational/Managerial Control · Individual
Nickerson, Kirby
Corporate Officer · Individual
Smith, Kesha
Operational/Managerial Control · Individual
Smith, Kesha
Corporate Director · Individual
Wilmouth, Logan
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Willow Valley Center for Nursing and Rehabilitatio
Winston-Salem, NC
1-star overall rating with 1-star inspections with $283,330 in total fines with 9 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Arbor Acres United Methodist Retirement Community
Winston Salem, NC
4-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
#3
Brookridge Retirement Community
Winston-Salem, NC
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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