Trinity Oaks

820 Klumac Road
Salisbury, NC, 28144
7046373784
CCN: 345153
4
Overall
3
Health
5
Staffing
3
Quality
ChainLUTHERAN SERVICES CAROLINAS
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
LUTHERAN SERVICES FOR THE AGING, INC.5% OR GREATER DIRECT OWNERSHIP INTEREST100%
SMITH, KESHACORPORATE DIRECTORNOT APPLICABLE
NICKERSON, KIRBYCORPORATE OFFICERNOT APPLICABLE
MADDRY, KARENCORPORATE OFFICERNOT APPLICABLE
CORNELISON, TIMOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
GOINS, TEDOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
NICKERSON, KIRBYOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
SMITH, KESHAOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
LUTHERAN HOME AT TRINITY OAKS PROPERTY INCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
LSA MANAGEMENT, INC.OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
AMIN, CHETANOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Health Deficiencies (17)
2025-02-24 · Health
D
F761 · Pharmacy Service Deficiencies
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.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
D
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
D
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
E
F584 · Resident Rights Deficiencies
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.
2023-10-26 · Health
D
F867 · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F
F851 · Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
E
F814 · Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F761 · Pharmacy Service Deficiencies
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.
D
F693 · Quality of Life and Care Deficiencies
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.
D
F690 · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
D
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2022-03-30 · Health
E
F761 · Pharmacy Service Deficiencies
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.
D
F756 · Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
4.76
3.68
RN Hrs/Resident/Day
0.77
0.54
LPN Hrs/Resident/Day
0.70
0.81
CNA Hrs/Resident/Day
3.29
2.33
PT Hrs/Resident/Day
0.03
0.12
Data as of 2026-03-01