Home › North Carolina › Rowan County › Trinity Oaks
Trinity Oaks
820 Klumac Road, Salisbury, NC 28144 · CMS Certification Number (CCN) 345153
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At a glance
- CMS overall rating
- ★★★★★ 5 of 5
- Health inspection citations
- 15 in the last 3 inspection cycles (0 immediate jeopardy, 0 actual harm, 3 from complaints)
- Fire safety citations
- 9
- Fines (last 3 years)
- 0 fines, total $0
- Payment denials
- 0
- Most recent standard inspection
- April 2, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Overall | ★★★★★ 5 of 5 | 2.9 | 3 |
| Health inspections | ★★★★☆ 4 of 5 | 2.9 | 2.8 |
| Staffing | ★★★★★ 5 of 5 | 2.7 | 2.9 |
| Quality measures | ★★★☆☆ 3 of 5 | 3.3 | 3.6 |
| Long-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
| Short-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | April 2, 2026 | 0 | 0 | 0 |
| Cycle 2 | February 24, 2025 | 7 | 6 | 3 |
CMS weighted health inspection score: 8 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
15 health citations across 2 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
February 24, 2025: 6 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/13/2025 |
| D | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/14/2025 |
| D | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/20/2025 |
| D | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/06/2025 |
| D | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/06/2025 |
| E | F-0584 | 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. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/06/2025 |
October 26, 2023: 9 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 11/17/2023 |
| F | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 11/17/2023 |
| D | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 11/17/2023 |
| E | F-0814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 11/17/2023 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 11/17/2023 |
| D | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 11/17/2023 |
| D | F-0693 | 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. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 11/17/2023 |
| D | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 11/17/2023 |
| D | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/17/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
9 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 04/02/2026 | D | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies | Deficient, Provider has date of correction Corrected 06/24/2026 |
| 04/02/2026 | D | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/24/2026 |
| 02/24/2025 | D | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 04/07/2025 |
| 02/24/2025 | D | K-0161 | Use approved construction type or materials. Construction Deficiencies | Deficient, Provider has date of correction Corrected 04/07/2025 |
| 10/26/2023 | F | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 03/29/2024 |
| 10/26/2023 | D | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 03/29/2024 |
| 10/26/2023 | D | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 03/29/2024 |
| 10/26/2023 | E | K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Egress Deficiencies | Deficient, Provider has date of correction Corrected 03/29/2024 |
| 10/26/2023 | E | K-0161 | Use approved construction type or materials. Construction Deficiencies | Deficient, Provider has date of correction Corrected 03/29/2024 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
No fines or payment denials published for this facility in the CMS Penalties file (last 3 years).
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 4.3 | 3.85 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.83 | 0.62 | 0.69 |
| LPN/LVN hours per resident per day | 0.54 | Not published | Not published |
| Nurse aide hours per resident per day | 2.93 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.7 | Not published | Not published |
| RN hours per resident per day, weekends | 0.57 | Not published | Not published |
| Total nursing staff turnover (%) | 30.1 | 49 | 45.8 |
| Registered nurse turnover (%) | 19 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Lutheran Home at Trinity Oaks, INC.
- Ownership type
- Non profit - Corporation
- Chain
- Lutheran Services Carolinas (9 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 115
- Average residents per day
- 108.2
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- Yes
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- April 1, 1976
- County/parish
- Rowan
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
24 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| GOINS, TED | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HERMAN, RICHARD | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MADDRY, KAREN | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NELSON, DOUGLAS | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SMITH, KESHA | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MADDRY, KAREN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NICKERSON, KIRBY | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LSA MANAGEMENT, INC. | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| LUTHERAN HOME AT TRINITY OAKS PROPERTY INC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| AMIN, CHETAN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CORNELISON, TIM | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GOINS, TED | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NICKERSON, KIRBY | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SMITH, KESHA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LUTHERAN SERVICES FOR THE AGING, INC. | TRUSTEE OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| GOINS, TED | TRUSTEE OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HERMAN, RICHARD | TRUSTEE OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NELSON, DOUGLAS | TRUSTEE OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LSA MANAGEMENT, INC. | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| LUTHERAN HOME AT TRINITY OAKS PROPERTY INC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| AMIN, CHETAN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CORNELISON, TIM | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NICKERSON, KIRBY | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SMITH, KESHA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Trinity Oaks. Full inspection reports, quality measures and staffing.
- DHSR Complaint Intake Unit: File a Complaint. The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.