| Trinity Oaks | |
| 820 Klumac Road, Salisbury, North Carolina 28144 | |
| (704) 637-3784 | |
| Name | Trinity Oaks |
|---|---|
| Location | 820 Klumac Road, Salisbury, North Carolina |
| Certified By | Medicare and Medicaid |
| No. of Certified Beds | 115 |
| Occupancy Rate | 94.09% |
| Medicare ID (CCN) | 345153 |
| Legal Business Name | Lutheran Home at Trinity Oaks, Inc. |
| Ownership Type | Non Profit - Corporation |
| Chain | Lutheran Services Carolinas (9 nursing homes) |
| Chain Average Overall Rating | 4.2 out of 5 |
| NPI Number | 1447254149 |
| Match | Confirmed listed in Medicare enrollment records |
| Organization Name | Lutheran Home at Trinity Oaks, Inc. |
| Doing Business As | Lutheran Home at Trinity Oaks |
| Address | 820 Klumac Rd, Salisbury, NC 28144 |
| Phone Number | 704-637-3784 |
| Ratings from Surveys (Inspections): | |
| Ratings from Quality Measures: | |
| Ratings from Staffing Data: | |
| Overall Rating: |
|---|
| Staffing Measure | Provider | National Avg. |
|---|---|---|
| Total nurse staff hours per resident per day | 4.3 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.83 | 0.69 |
| Licensed practical nurse (LPN) hours per resident per day | 0.54 | 0.86 |
| Nurse aide hours per resident per day | 2.93 | 2.32 |
| Total nurse staff hours per resident per day on the weekend | 3.7 | 3.42 |
| RN hours per resident per day on the weekend | 0.57 | 0.48 |
| Physical therapist hours per resident per day | 0.04 | 0.07 |
| Total nursing staff turnover | 30.1% | 45.8% |
| Registered nurse turnover | 19% | 42.9% |
| Number of administrators who have left the nursing home | 0 | 0.5 |
| Cited for abuse, neglect or exploitation of residents (Care Compare abuse icon) | No |
| Number of Fines | 0 |
| Total Amount of Fines in Dollars | $0 |
| Number of Payment Denials | 0 |
| Total Number of Penalties | 0 |
| Date | Deficiency | Harm Level | Status |
|---|---|---|---|
| Feb 24, 2025 | 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. F0584, Resident Rights, Standard inspection | Potential for harm, pattern | Corrected by Mar 6, 2025 |
| Feb 24, 2025 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. F0600, Freedom from Abuse, Neglect, and Exploitation, Standard inspection, Complaint inspection | Potential for harm, isolated | Corrected by Mar 6, 2025 |
| Feb 24, 2025 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. F0607, Freedom from Abuse, Neglect, and Exploitation, Standard inspection | Potential for harm, isolated | Corrected by Mar 6, 2025 |
| Feb 24, 2025 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609, Freedom from Abuse, Neglect, and Exploitation, Standard inspection | Potential for harm, isolated | Corrected by Mar 20, 2025 |
| Feb 24, 2025 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Standard inspection, Complaint inspection | Potential for harm, isolated | Corrected by Mar 14, 2025 |
| Feb 24, 2025 | 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. F0761, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Mar 13, 2025 |
| Oct 26, 2023 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. F0851, Administration, Standard inspection | Potential for harm, widespread | Corrected by Nov 17, 2023 |
| Oct 26, 2023 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, pattern | Corrected by Nov 17, 2023 |
| Oct 26, 2023 | Dispose of garbage and refuse properly. F0814, Nutrition and Dietary, Standard inspection | Potential for harm, pattern | Corrected by Nov 17, 2023 |
| Oct 26, 2023 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. F0550, Resident Rights, Complaint inspection | Potential for harm, isolated | Corrected by Nov 17, 2023 |
| Oct 26, 2023 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. F0690, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Nov 17, 2023 |
| Oct 26, 2023 | 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. F0693, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Nov 17, 2023 |
| Oct 26, 2023 | 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. F0761, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Nov 17, 2023 |
| Oct 26, 2023 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. F0842, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Nov 17, 2023 |
| Oct 26, 2023 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. F0867, Administration, Standard inspection | Potential for harm, isolated | Corrected by Nov 17, 2023 |
| Quality Measure | Provider | National Avg. |
|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.5 | 13.87 |
| Percentage of long-stay residents who lose too much weight | 8.02 | 5.19 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2 | 0.82 |
| Percentage of long-stay residents with a urinary tract infection | 2.03 | 1.59 |
| Percentage of long-stay residents who have depressive symptoms | 0.81 | 12.8 |
| Percentage of long-stay residents who were physically restrained | 0 | 0.13 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.29 | 3.23 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.39 | 93.55 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.08 | 82.04 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0 | 1.56 |
| Percentage of long-stay residents whose ability to walk independently worsened | 30.72 | 14.07 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.24 | 19.52 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 78.85 | 95.46 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.5 | 79.75 |
| Percentage of long-stay residents with pressure ulcers | 6.43 | 4.62 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.9 | 19.01 |
| Percentage of long-stay residents who received an antipsychotic medication | 3.36 | 15.38 |
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