Cycle 1
Health 2025-03-27 · Fire 2025-03-27
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Hickory, NC
Trinity Ridge
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2140 Medical Park Drive, Hickory, NC
(828) 322-6995
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
120
Certified beds
Average residents
112
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lutheran Services Carolinas
Operator or chain grouping
Approved since
1973-12-10
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
0.88
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.44
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
3.32
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.63
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
4.18
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.69
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.91
CMS adjusted RN staffing hours
Adjusted total hours
4.80
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,341
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9899
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.93
Baseline 16.95% · Performance 19.14% · Measure score 4.93 · Achievement 4.93 · Improvement 0
Healthcare-associated infections
0
Baseline 6.01% · Performance 8.34% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5
Baseline 42.48% · Performance 43.26% · Measure score 5 · Achievement 5 · Improvement 0
Adjusted total nurse staffing
4.68
Baseline 3.52 hours · Performance 4.41 hours · Measure score 4.68 · Achievement 4.68 · Improvement 3.44
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.89% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 278 · Observed rate 5.04% · Lower 95% interval 6.01% |
| Discharge to community | 59.59% |
50.57%
9 pts better
|
Better than the National Rate · Eligible stays 252 · Observed rate 63.1% · Lower 95% interval 55.37% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 95.24% |
95.27%
About the same
|
Numerator 140 · Denominator 147 |
| Falls with major injury | 0.68% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 147 |
| Discharge self-care score | 68.22% |
53.69%
14.5 pts better
|
Numerator 88 · Denominator 129 |
| Discharge mobility score | 76.74% |
50.94%
25.8 pts better
|
Numerator 99 · Denominator 129 |
| Pressure ulcers or injuries, new or worsened | 4.08% |
2.29%
1.8 pts worse
|
Numerator 6 · Denominator 147 · Adjusted rate 4.84% |
| Healthcare-associated infections requiring hospitalization | 8.34% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 166 · Observed rate 7.23% · Lower 95% interval 5.59% |
| Staff COVID-19 vaccination coverage | 4.85% |
8.2%
3.3 pts worse
|
Numerator 10 · Denominator 206 |
| Staff flu vaccination coverage | 15.06% |
42%
26.9 pts worse
|
Numerator 39 · Denominator 259 |
| Discharge function score | 75.97% |
56.45%
19.5 pts better
|
Numerator 98 · Denominator 129 |
| Transfer of health information to provider | 97.5% |
95.95%
1.5 pts better
|
Numerator 78 · Denominator 80 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 27.54% |
25.2%
2.3 pts better
|
Numerator 19 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · 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 0.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 80.0% |
91.5%
11.5 pts worse
|
93.4%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.7% · Q2 82.4% · Q3 62.2% · Q4 80.0% · 4Q avg 80.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.0% |
94.1%
1.9 pts better
|
95.5%
0.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
3.6%
0.8 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 3.3% · Q3 4.4% · Q4 3.3% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
4.8%
3.3 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 2.3% · Q4 2.3% · 4Q avg 1.5% |
| Percentage of long-stay residents who lose too much weight | 12.8% |
7.2%
5.6 pts worse
|
5.4%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 14.9% · Q3 6.8% · Q4 10.7% · 4Q avg 12.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.1% |
21.6%
0.5 pts better
|
19.6%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.0% · Q2 20.8% · Q3 18.7% · Q4 24.0% · 4Q avg 21.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.3% |
15.0%
2.3 pts worse
|
16.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 16.9% · Q3 18.8% · Q4 13.8% · 4Q avg 17.3% · 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 | 56.3% |
21.5%
34.8 pts worse
|
16.3%
40 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 68.1% · Q2 50.9% · Q3 57.0% · Q4 40.8% · 4Q avg 56.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 41.7% |
16.8%
24.9 pts worse
|
14.9%
26.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.1% · Q2 32.4% · Q3 47.1% · Q4 53.7% · 4Q avg 41.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
0.9%
2.1 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.5% · Q3 2.3% · Q4 4.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 9.1% |
2.6%
6.5 pts worse
|
1.7%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 8.0% · Q3 13.5% · Q4 8.9% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.9% |
21.2%
10.7 pts worse
|
19.8%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.0% · Q2 32.8% · Q3 34.9% · Q4 26.7% · 4Q avg 31.9% |
| 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 4.3% · Q2 4.9% · Q3 3.9% · Q4 3.5% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
79.9%
14.7 pts better
|
81.7%
12.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 96.2% · Q3 95.0% · Q4 89.8% · 4Q avg 94.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
13.2%
5.3 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 7.8% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.3% · Q4 3.4% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.9% |
78.1%
11.8 pts better
|
79.7%
10.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.6% |
22.9%
2.3 pts better
|
23.9%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.6% · Observed 18.3% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-29 · Fire 2023-11-29
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2022-06-09 · Fire 2022-06-09
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-27
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 2025-05-31
D · Potential for more than minimal harm
2025-03-27
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-05-31
D · Potential for more than minimal harm
2023-11-29
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-04-01
D · Potential for more than minimal harm
2023-11-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-01
D · Potential for more than minimal harm
2022-06-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-07-22
D · Potential for more than minimal harm
2022-06-09
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-07-22
D · Potential for more than minimal harm
2022-06-09
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-07-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-17
D · Potential for more than minimal harm
2025-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-16
D · Potential for more than minimal harm
2023-11-29
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 2023-08-21
Penalties and ownership
What sits behind the stars
Ownership
Corder, John
Operational/Managerial Control · Individual
Goins, Ted
Operational/Managerial Control · Individual
Huffman, Hannah
Operational/Managerial Control · Individual
Lsa Management, Inc.
Operational/Managerial Control · Organization
Lutheran Home Hickory West Property, Inc.
Operational/Managerial Control · Organization
Maddry, Karen
Corporate Officer · Individual
Nickerson, Kirby
Corporate Officer · Individual
Smith, Kesha
Operational/Managerial Control · Individual
Smith, Kesha
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
The Greens at Hickory
Hickory, NC
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
The Greens at Viewmont
Hickory, NC
3-star overall rating with 3-star inspections with $16,801 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Trinity Village
Hickory, NC
5-star overall rating with 4-star inspections with $8,512 in total fines with 2 fire-safety deficiencies in the latest cycle
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