Cycle 1
Health 2025-02-24 · Fire 2025-02-24
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Salisbury, NC
Trinity Oaks
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
820 Klumac Road, Salisbury, NC
(704) 637-3784
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
115
Certified beds
Average residents
109
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lutheran Services Carolinas
Operator or chain grouping
Approved since
1976-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.77
Registered nurse staffing
LPN hours / resident day
0.70
Licensed practical nurse staffing
Aide hours / resident day
3.29
Nurse aide staffing
Weekend hours
4.13
Weekend nurse staffing
RN turnover
10%
Annual RN turnover
Total nurse turnover
30%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.8% |
91.5%
3.7 pts worse
|
93.4%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 78.8% |
94.1%
15.3 pts worse
|
95.5%
16.7 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.6%
1.6 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
4.8%
2.8 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.5% |
7.2%
0.3 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.0% |
21.6%
2.6 pts better
|
19.6%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 7.5% |
15.0%
7.5 pts better
|
16.7%
9.2 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 | 34.0% |
21.5%
12.5 pts worse
|
16.3%
17.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.3% |
16.8%
4.5 pts worse
|
14.9%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
2.6%
0.3 pts better
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.5% |
21.2%
12.3 pts worse
|
19.8%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 9.5% |
6.0%
3.5 pts worse
|
5.1%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.2% |
79.9%
0.7 pts worse
|
81.7%
2.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.1% |
13.2%
7.1 pts better
|
12.0%
5.9 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.5% |
78.1%
9.4 pts better
|
79.7%
7.8 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.9% |
22.9%
1 pts worse
|
23.9%
About the same
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-26 · Fire 2023-10-26
8 health deficiencies
Top issue: Administration (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-03-30 · Fire 2022-03-30
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-24
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-02-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-07
F · Potential for more than minimal harm
2023-10-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-29
E · Potential for more than minimal harm
2023-10-26
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-03-29
E · Potential for more than minimal harm
2023-10-26
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 2024-03-29
D · Potential for more than minimal harm
2023-10-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-29
D · Potential for more than minimal harm
2023-10-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-29
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-24
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-24
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-24
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-24
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-24
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 2025-03-14
D · Potential for more than minimal harm
2025-02-24
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 2025-03-13
F · Potential for more than minimal harm
2023-10-26
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-26
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 2023-11-17
E · Potential for more than minimal harm
2023-10-26
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
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 2023-11-17
D · Potential for more than minimal harm
2023-10-26
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 2023-11-17
D · Potential for more than minimal harm
2023-10-26
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
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 2023-11-17
D · Potential for more than minimal harm
2023-10-26
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-11-17
E · Potential for more than minimal harm
2022-03-30
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 2022-04-11
D · Potential for more than minimal harm
2022-03-30
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-04-11
Penalties and ownership
What sits behind the stars
Ownership
Lutheran Services For The Aging, Inc.
5% Or Greater Direct Ownership Interest · Organization
Amin, Chetan
Operational/Managerial Control · Individual
Cornelison, Tim
Operational/Managerial Control · Individual
Goins, Ted
Operational/Managerial Control · Individual
Lsa Management, Inc.
Operational/Managerial Control · Organization
Lutheran Home At Trinity Oaks 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
Nearby options
Other facilities in reach
#1
Piedmont Health & Rehab Center
Salisbury, NC
3-star overall rating with 3-star inspections with $8,512 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
NC State Veterans Home - Salisbury
Salisbury, NC
3-star overall rating with 2-star inspections with $19,145 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Autumn Care of Salisbury
Salisbury, NC
3-star overall rating with 3-star inspections with $8,738 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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