Cycle 1
Health 2025-01-15 · Fire 2025-01-15
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Hickory, NC
Trinity Village
5-star overall rating with 4-star inspections with $8,512 in total fines with 2 fire-safety deficiencies in the latest cycle
1265 21 Street NE, Hickory, NC
(828) 328-2006
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
104
Certified beds
Average residents
98
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lutheran Services Carolinas
Operator or chain grouping
Approved since
1976-07-01
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
1.09
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
4.83
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
6.60
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.77
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
5.81
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.72
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
1.12
CMS adjusted RN staffing hours
Adjusted total hours
6.76
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,999
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.38
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
2.29
Baseline 19.43% · Performance 20.37% · Measure score 2.29 · Achievement 2.29 · Improvement 0
Healthcare-associated infections
2.62
Baseline 4.72% · Performance 7.05% · Measure score 2.62 · Achievement 2.62 · Improvement 0
Total nurse turnover
6.04
Baseline 43.90% · Performance 39.01% · Measure score 6.04 · Achievement 6.04 · Improvement 2.07
Adjusted total nurse staffing
10
Baseline 3.53 hours · Performance 6.66 hours · Measure score 10 · Achievement 10 · Improvement 9
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 245 · Observed rate 8.57% · Lower 95% interval 8.3% |
| Discharge to community | 60.56% |
50.57%
10 pts better
|
Better than the National Rate · Eligible stays 240 · Observed rate 60.42% · Lower 95% interval 53.62% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.36% |
95.27%
3.1 pts better
|
Numerator 120 · Denominator 122 |
| Falls with major injury | 1.64% |
0.77%
0.9 pts worse
|
Numerator 2 · Denominator 122 |
| Discharge self-care score | 56.73% |
53.69%
3 pts better
|
Numerator 59 · Denominator 104 |
| Discharge mobility score | 58.65% |
50.94%
7.7 pts better
|
Numerator 61 · Denominator 104 |
| Pressure ulcers or injuries, new or worsened | 2.46% |
2.29%
0.2 pts worse
|
Numerator 3 · Denominator 122 · Adjusted rate 2.95% |
| Healthcare-associated infections requiring hospitalization | 7.05% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 127 · Observed rate 5.51% · Lower 95% interval 4.42% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 303 |
| Staff flu vaccination coverage | 27.65% |
42%
14.4 pts worse
|
Numerator 133 · Denominator 481 |
| Discharge function score | 54.81% |
56.45%
1.6 pts worse
|
Numerator 57 · Denominator 104 |
| Transfer of health information to provider | 98.55% |
95.95%
2.6 pts better
|
Numerator 68 · Denominator 69 |
| Transfer of health information to patient | 95.83% |
96.28%
0.5 pts worse
|
Numerator 23 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 26.09% |
25.2%
0.9 pts better
|
Numerator 18 · Denominator 69 |
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 · Adjusted 1.4 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.5%
8.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
94.1%
2.6 pts better
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| 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 6.0% · Q2 4.9% · Q3 6.0% · Q4 2.4% · 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 | 7.9% |
7.2%
0.7 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 10.5% · Q3 6.2% · Q4 10.1% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.2% |
21.6%
15.6 pts worse
|
19.6%
17.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.8% · Q2 38.0% · Q3 37.0% · Q4 40.0% · 4Q avg 37.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.4% |
15.0%
5.4 pts worse
|
16.7%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 21.7% · Q3 20.0% · Q4 22.2% · 4Q avg 20.4% · 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 | 16.7% |
21.5%
4.8 pts better
|
16.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.0% · Q2 10.7% · Q3 7.3% · Q4 14.1% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.8% |
16.8%
6 pts worse
|
14.9%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.9% · Q2 24.7% · Q3 19.7% · Q4 16.7% · 4Q avg 22.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
0.9%
1.3 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.2% · Q3 3.6% · Q4 0.9% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
2.6%
0.5 pts better
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.6% · Q3 1.2% · Q4 2.4% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.2% |
21.2%
8 pts worse
|
19.8%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 32.0% · Q3 29.8% · Q4 27.6% · 4Q avg 29.2% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
6.0%
0.9 pts better
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 7.4% · Q3 3.8% · Q4 5.8% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
79.9%
19.9 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.1% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.5% |
13.2%
2.3 pts worse
|
12.0%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.5% · Observed 13.9% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
78.1%
18.3 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.9% |
22.9%
3 pts better
|
23.9%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.9% · Observed 15.8% · Expected 19.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-31 · Fire 2023-10-31
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-04-28 · Fire 2022-04-28
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-01-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-01-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-31
D · Potential for more than minimal harm
2023-10-31
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-14
D · Potential for more than minimal harm
2023-10-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-14
D · Potential for more than minimal harm
2023-10-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-14
F · Potential for more than minimal harm
2022-04-28
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-06-22
F · Potential for more than minimal harm
2022-04-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-06-22
D · Potential for more than minimal harm
2022-04-28
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 2022-06-22
D · Potential for more than minimal harm
2022-04-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-06-22
Inspection history
Recent health citations
G · Actual harm
2024-04-23
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 2024-01-03
D · Potential for more than minimal harm
2024-04-23
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-01-03
D · Potential for more than minimal harm
2022-04-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-05-19
Penalties and ownership
What sits behind the stars
$8,512
2024-04-23
Fine
Fine · fine $8,512
Fine
Ownership
Desantis, Michael
Operational/Managerial Control · Individual
Goins, Ted
Operational/Managerial Control · Individual
Hendren, Kendra
Operational/Managerial Control · Individual
Lsa Management, Inc.
Operational/Managerial Control · Organization
Lutheran Home Hickory West Property, Inc.
Operational/Managerial Control · Organization
Lutheran Services For The Aging, Inc.
Operational/Managerial Control · Organization
Maddry, Karen
Corporate Officer · Individual
Nelson, Douglas
Operational/Managerial Control · Individual
Nelson, Douglas
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
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
#2
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
#3
Trinity Ridge
Hickory, NC
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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