Cycle 1
Health 2025-11-20 · Fire 2024-10-10
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Albemarle, NC
Trinity Place
5-star overall rating with 4-star inspections with $13,520 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
24724 South Business 52, Albemarle, NC
(704) 982-8191
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
76
Certified beds
Average residents
71
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lutheran Services Carolinas
Operator or chain grouping
Approved since
1973-10-04
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
0.62
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.78
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.52
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.74
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
4.16
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
4.93
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,997
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.39
Composite VBP score used to determine payment impact.
Payment multiplier
1.0069
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.75
Baseline 17.27% · Performance 20.16% · Measure score 2.75 · Achievement 2.75 · Improvement 0
Healthcare-associated infections
2.64
Baseline 5.34% · Performance 7.05% · Measure score 2.64 · Achievement 2.64 · Improvement 0
Total nurse turnover
9.32
Baseline 45.56% · Performance 25.58% · Measure score 9.32 · Achievement 9.32 · Improvement 9
Adjusted total nurse staffing
6.25
Baseline 4.32 hours · Performance 4.86 hours · Measure score 6.25 · Achievement 6.25 · Improvement 3.18
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.97% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 130 · Observed rate 4.62% · Lower 95% interval 6.12% |
| Discharge to community | 57.58% |
50.57%
7 pts better
|
No Different than the National Rate · Eligible stays 130 · Observed rate 55.38% · Lower 95% interval 49.34% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 72 · Denominator 72 |
| Falls with major injury | 1.39% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 72 |
| Discharge self-care score | 25% |
53.69%
28.7 pts worse
|
Numerator 15 · Denominator 60 |
| Discharge mobility score | 40% |
50.94%
10.9 pts worse
|
Numerator 24 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 6.94% |
2.29%
4.7 pts worse
|
Numerator 5 · Denominator 72 · Adjusted rate 7.15% |
| Healthcare-associated infections requiring hospitalization | 7.05% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 5.56% · Lower 95% interval 4.05% |
| Staff COVID-19 vaccination coverage | 0.63% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 159 |
| Staff flu vaccination coverage | 21.88% |
42%
20.1 pts worse
|
Numerator 49 · Denominator 224 |
| Discharge function score | 23.33% |
56.45%
33.1 pts worse
|
Numerator 14 · Denominator 60 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 44 · Denominator 44 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 17.5% |
25.2%
7.7 pts worse
|
Numerator 7 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| 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 · Adjusted 1.3 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.6% |
91.5%
1.9 pts worse
|
93.4%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.4% · Q2 90.0% · Q3 79.3% · Q4 95.2% · 4Q avg 89.6% |
| 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 | 2.1% |
3.6%
1.5 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 0.0% · Q3 1.7% · Q4 1.6% · 4Q avg 2.1% · 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 | 10.3% |
7.2%
3.1 pts worse
|
5.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 10.6% · Q3 12.2% · Q4 14.0% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.7% |
21.6%
16.1 pts worse
|
19.6%
18.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.9% · Q2 31.2% · Q3 40.0% · Q4 34.6% · 4Q avg 37.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.9% |
15.0%
5.9 pts worse
|
16.7%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 25.6% · Q3 20.9% · Q4 18.2% · 4Q avg 20.9% · 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 | 23.0% |
21.5%
1.5 pts worse
|
16.3%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 17.6% · Q3 25.1% · 4Q avg 23.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.1% |
16.8%
0.7 pts better
|
14.9%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 8.9% · Q3 18.8% · Q4 18.8% · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
0.9%
1.9 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 2.4% · Q3 2.1% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
2.6%
0.8 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.4% · Q3 3.5% · Q4 5.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.5% |
21.2%
2.3 pts worse
|
19.8%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 10.7% · Q3 33.0% · Q4 24.4% · 4Q avg 23.5% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
6.0%
1.9 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 4.8% · Q3 3.1% · Q4 4.7% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.8% |
79.9%
1.9 pts better
|
81.7%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 70.2% · Q2 73.8% · Q3 84.8% · Q4 96.9% · 4Q avg 81.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.2% |
13.2%
3 pts worse
|
12.0%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 14.9% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.9% |
78.1%
14.8 pts better
|
79.7%
13.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.2% |
22.9%
4.3 pts worse
|
23.9%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 22.4% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-10 · Fire 2023-06-08
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-06-08 · Fire 2021-12-16
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
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
2024-10-10
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-10-10
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 2024-12-05
D · Potential for more than minimal harm
2023-06-08
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-06-08
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 2023-09-27
D · Potential for more than minimal harm
2023-06-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-06-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-06-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-06-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-27
C · Minimal harm
2023-06-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-27
Inspection history
Recent health citations
B · Minimal harm
2025-11-20
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Not marked corrected
G · Actual harm
2025-09-19
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.
Not marked corrected
E · Potential for more than minimal harm
2023-06-08
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 2023-06-23
Penalties and ownership
What sits behind the stars
$13,520
2025-09-19
Fine
Fine · fine $13,520
Fine
Ownership
Lutheran Services For The Aging, Inc.
5% Or Greater Direct Ownership Interest · Organization
Gabriel, Eric
Operational/Managerial Control · Individual
Goins, Ted
Operational/Managerial Control · Individual
Lsa Management, Inc.
Operational/Managerial Control · Organization
Lutheran Home Albemarle Property Inc.
Operational/Managerial Control · Organization
Lutheran Services For The Aging, Inc.
Operational/Managerial Control · Organization
Maddry, Karen
Corporate Officer · Individual
Nickerson, Kirby
Operational/Managerial Control · Individual
Nickerson, Kirby
Corporate Officer · Individual
Omura, Akiko
Operational/Managerial Control · Individual
Smith, Kesha
Operational/Managerial Control · Individual
Smith, Kesha
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Forrest Oakes Healthcare
Albemarle, NC
2-star overall rating with 2-star inspections with $5,242 in total fines with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Stanly Manor
Albemarle, NC
2-star overall rating with 2-star inspections with $12,054 in total fines with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Bethany Woods Nursing and Rehabilitation Center
Albemarle, NC
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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