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
Chain footprint
9 facilities
Chain averages 4 overall / 4 health / 5 staffing / 3 quality stars
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
0.57
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
3.42
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.72
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
4.31
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
5.33
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,859
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9914
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.39
Baseline 22.27% · Performance 20.23% · Measure score 3.39 · Achievement 2.58 · Improvement 3.39
Healthcare-associated infections
0
Baseline 6.84% · Performance 8.09% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.80
Baseline 33.95% · Performance 44.06% · Measure score 4.80 · Achievement 4.80 · Improvement 0
Adjusted total nurse staffing
7.14
Baseline 4.21 hours · Performance 5.11 hours · Measure score 7.14 · Achievement 7.14 · Improvement 5.24
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.63% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 9.84% · Lower 95% interval 7.16% |
| Discharge to community | 43.77% |
50.57%
6.8 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 36.21% · Lower 95% interval 30.51% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 93.1% |
95.27%
2.2 pts worse
|
Numerator 27 · Denominator 29 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 29 |
| Discharge self-care score | 40% |
53.69%
13.7 pts worse
|
Numerator 8 · Denominator 20 |
| Discharge mobility score | 40% |
50.94%
10.9 pts worse
|
Numerator 8 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 13.79% |
2.29%
11.5 pts worse
|
Numerator 4 · Denominator 29 · Adjusted rate 9.82% |
| Healthcare-associated infections requiring hospitalization | 8.09% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 12.12% · Lower 95% interval 3.33% |
| Staff COVID-19 vaccination coverage | 4.84% |
8.2%
3.4 pts worse
|
Numerator 15 · Denominator 310 |
| Staff flu vaccination coverage | 50.38% |
42%
8.4 pts better
|
Numerator 198 · Denominator 393 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 10 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
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 · Adjusted 0.9 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| 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 · Adjusted 1.0 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| 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 · Q1 80.4% · Q2 91.8% · Q3 92.5% · Q4 92.3% · 4Q avg 89.5% |
| 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 · 4Q avg 97.0% |
| 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 · Q1 4.3% · Q2 5.2% · Q3 5.7% · Q4 3.8% · 4Q avg 4.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 11.6% · Q2 6.9% · Q3 8.2% · Q4 7.3% · 4Q avg 8.4% |
| 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 · Q1 18.4% · Q2 24.1% · Q3 19.4% · Q4 16.7% · 4Q avg 19.6% |
| 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 · Q1 16.7% · Q2 13.8% · Q3 16.9% · Q4 14.3% · 4Q avg 15.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.3% |
| 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 · 4Q avg 30.0% · Used in QM five-star |
| 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 · Q1 20.3% · Q2 29.6% · Q3 17.6% · Q4 18.6% · 4Q avg 21.4% · Used in QM five-star |
| 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 · Q1 4.2% · Q2 3.2% · Q3 1.3% · Q4 1.2% · 4Q avg 2.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 3.1% · Q3 0.0% · Q4 1.0% · 4Q avg 1.0% · Used in QM five-star |
| 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 · Q1 27.2% · Q2 33.6% · Q3 26.1% · Q4 33.0% · 4Q avg 30.0% |
| 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 · Q1 4.9% · Q2 6.4% · Q3 5.3% · Q4 7.8% · 4Q avg 6.1% · Used in QM five-star |
| 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 · Q1 92.5% · Q2 90.5% · Q3 98.3% · Q4 96.2% · 4Q avg 94.0% |
| 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 · Q1 0.0% · Q2 4.5% · Q3 0.0% · Q4 2.8% · 4Q avg 1.9% · Used in QM five-star |
| 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 · 4Q avg 81.6% |
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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