Trinity Oaks
820 Klumac Road
Salisbury, NC, 28144
7046373784
CCN: 345153
4
Overall3
Health5
Staffing3
QualitySpecial FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
| Name | Role | % |
|---|---|---|
| LUTHERAN SERVICES FOR THE AGING, INC. | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| SMITH, KESHA | CORPORATE DIRECTOR | NOT APPLICABLE |
| NICKERSON, KIRBY | CORPORATE OFFICER | NOT APPLICABLE |
| MADDRY, KAREN | CORPORATE OFFICER | NOT APPLICABLE |
| CORNELISON, TIM | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| GOINS, TED | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| NICKERSON, KIRBY | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| SMITH, KESHA | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| LUTHERAN HOME AT TRINITY OAKS PROPERTY INC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| LSA MANAGEMENT, INC. | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| AMIN, CHETAN | OPERATIONAL/MANAGERIAL CONTROL | NOT 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/Day3.68
4.76
RN Hrs/Resident/Day0.54
0.77
LPN Hrs/Resident/Day0.81
0.70
CNA Hrs/Resident/Day2.33
3.29
PT Hrs/Resident/Day0.12
0.03
Data as of 2026-03-01