What is Trinity Oaks's Medicare star rating?

CMS rates Trinity Oaks 5 out of 5 stars overall, with 4 for health inspections, 5 for staffing and 3 for quality measures (CMS data as of September 1, 2026).

How many deficiencies did Trinity Oaks get at its last inspection?

0 health deficiencies at the standard inspection on April 2, 2026. The North Carolina average is 4.7.

Has Trinity Oaks been fined?

CMS lists no fines in the last three years.

Does Trinity Oaks accept Medicaid?

It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.

Who owns Trinity Oaks?

CMS lists 24 owners and managers, and links the home to Lutheran Services Carolinas. Legal business name: LUTHERAN HOME AT TRINITY OAKS, INC..

Trinity Oaks: Inspections, Staffing & Ratings

The record in brief

At its most recent standard inspection, on April 2, 2026, inspectors cited 0 health deficiencies (the North Carolina average is 4.7, the national average 9.2).

None of its 15 health citations since October 2023 was rated as actual harm or immediate jeopardy.

CMS lists no fines against this home in the last three years.

Nurses and nurse aides worked 4.30 hours per resident per day, against 3.85 across North Carolina and 3.86 nationally. Registered nurses accounted for 0.83 of those hours.

30.1% of nursing staff left within the year CMS measured (North Carolina average 49.0%).

CMS links it to Lutheran Services Carolinas, an affiliated group of 9 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

910/23

602/25

004/26

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 15 health citations on file.

Severity

Isolated

Pattern

Widespread

Immediate jeopardy

Actual harm

Potential for more than minimal harm

11D

Potential for minimal harm

April 2, 2026Standard inspection · 0 citations

February 24, 2025Standard inspection, Complaint inspection · 6 citations

E

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.

F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 6, 2025

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to maintain a clean shower room for 1 of 4 shower rooms reviewed for a safe, clean, comfortable, and homelike environment (The C-Hall shower room).
D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 6, 2025

Inspectors wroteBased on record review, and staff and the Responsible Party (RP) interviews, the facility failed to protect a resident's right to be free from staff to resident abuse. While Nurse Aide (NA) #5 was providing care for a cognitively impaired resident, the resident became agitated, was whining and crying. NA #5 placed part of her hand over the resident's mouth and told the resident to Hush, quit that whining. This deficient practice was found for 1 of 3 residents reviewed for abuse (Resident #16).
D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

F607 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 6, 2025

Inspectors wroteBased on record review and staff interviews, the facility failed to follow and implement abuse policies in the area of identification, protection and reporting for 1 of 3 residents reviewed for abuse (Resident #16). While Resident # 16 was being abused, Personal Care Assistant (PCA) #1 did not stop Nurse Aide (NA) #5 or intervene and did not report the incident immediately to licensed nursing staff or administrative staff. As a result, NA #5 worked the rest of her shift putting other residents at risk for abuse.
D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 20, 2025

Inspectors wroteBased on record review and staff interviews, the facility failed to include reported allegations in the initial report to the State Agency. Details were not accurately reflected for 1 of 3 residents reviewed for abuse (Resident #16).
D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 14, 2025

Inspectors wroteBased on record review and staff interviews, the facility failed to provide a safe transfer for 1 of 6 residents (Resident #69) reviewed for accidents.
D

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.

F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 13, 2025

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to secure medicated treatment supplies in a locked treatment cart for 1 of 1 treatment cart. Additionally, the facility failed to remove loose pills from a medication cart and failed to label medications which were not stored in their pharmacy or manufacturer packaging for 1 of 3 medication carts reviewed for medication storage (Unit B medication cart).

October 26, 2023Standard inspection, Complaint inspection · 9 citations

F

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

F851 · Administration · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) November 17, 2023

Inspectors wroteBased on staff interview and record review the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) for the 3rd quarter in fiscal year 2023. The facility did not report accurate weekend staffing and did not accurately report licensed nurse coverage 24 hours a day.
E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) November 17, 2023

Inspectors wroteBased on observations, staff interviews, and record review the facility failed to 1) remove expired foods/foods with signs of spoilage, 2) record a label on refrigerated and frozen foods that included date of opening and use by date, and 3) store foods in sealed containers. This failure had the potential to affect all residents who received food from the dietary department.
E

Dispose of garbage and refuse properly.

F814 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) November 17, 2023

Inspectors wroteBased on observations, interviews and record review, the facility failed to remove trash and debris on the ground around a commercial trash compactor and 3 of 3 commercial trash receptacles and maintain the commercial trash receptacle door closed.
D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 17, 2023

Inspectors wroteBased on record review, observations, resident and staff interviews, the facility failed to maintain a resident's dignity when a nurse used a loud voice directed toward 1 of 1 resident reviewed for dignity (Resident #38).
D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 17, 2023

Inspectors wroteBased on observations, resident, and staff interviews and record review, the facility failed to obtain a physician order for a suprapubic catheter size and balloon size (Resident #82) and failed to keep a catheter drainage bag and tubing from touching the floor to reduce the risk of infection or injury (Resident #246) for 2 of 3 sampled residents reviewed for the use of an indwelling urinary catheter.
D

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.

F693 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 17, 2023

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to provide an enteral product (liquid nutrition fed via a tube) continuous per physician order and record the date and time the enteral product was initially opened. This occurred for 1 of 2 sampled residents reviewed for nutrition from tube feedings.
D

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.

F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 17, 2023

Inspectors wroteBased on record reviews, observations, and staff interviews, the facility failed to discard expired insulin injection pens in 1 of 3 medication rooms (Medication room on A/B Hall) and in 1 of 5 medication carts (the secured unit medication cart) and monitor the temperature daily in 1 of 3 medication refrigerators (the C/D Hall medication refrigerator).
D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 17, 2023

Inspectors wroteBased on record reviews, and staff interviews, the facility failed to accurately document changing an indwelling suprapubic urinary catheter for 1 of 3 residents reviewed for urinary catheter documentation (Resident #82).
D

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

F867 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 17, 2023

Inspectors wroteBased on record review and staff interviews the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put into place following the 3/30/2022 recertification and complaint investigation survey. The deficiency was in the area of label and store drugs and biologicals (F761). The continued failure during two federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assurance Program.

Fire safety inspections

9 fire safety citations on file: 2 on April 2, 2026, 2 on February 24, 2025, 5 on October 26, 2023.

Every fire safety citation9 citations

D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

K 321 · April 2, 2026 · Corrected (the home has a date of correction)
D
Have properly installed electrical wiring and gas equipment.

K 511 · April 2, 2026 · Corrected (the home has a date of correction)
D
Use approved construction type or materials.

K 161 · February 24, 2025 · Corrected (the home has a date of correction)
D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

K 372 · February 24, 2025 · Corrected (the home has a date of correction)
F
Have generator or other power source capable of supplying service within 10 seconds.

K 918 · October 26, 2023 · Corrected (the home has a date of correction)
E
Use approved construction type or materials.

K 161 · October 26, 2023 · Corrected (the home has a date of correction)
E
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.

K 222 · October 26, 2023 · Corrected (the home has a date of correction)
D
Inspect, test, and maintain automatic sprinkler systems.

K 353 · October 26, 2023 · Corrected (the home has a date of correction)
D
Install corridor and hallway doors that block smoke.

K 363 · October 26, 2023 · Corrected (the home has a date of correction)

Fines and payment denials

CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

Measure	This home	North Carolina	United States
All nursing staff (RN, LPN and aides)	4.30	3.85	3.86
Registered nurses	0.83	0.62	0.69
All nursing staff on weekends	3.70	3.42	3.42
Nurse aides	2.93
Licensed practical nurses	0.54
Nursing staff turnover (share who left in a year)	30.1%	49.0%	45.8%
Registered nurse turnover	19.0%	45.6%	42.9%
Administrators who left	0

CMS expects 3.26 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.55 on weekdays and 3.70 on weekends, 19% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.66 in April to June 2025 to 4.30 in January to March 2026.

Quarter	All nursing staff	Registered nurses	Weekdays	Weekends	Contract staff share	Days with no RN hours	Residents a day
Jan to Mar 2026	4.30	0.83	4.55	3.70	0.0%	0 of 90	108
Oct to Dec 2025	4.85	0.77	5.08	4.25	0.0%	0 of 92	108
Jul to Sep 2025	4.76	0.77	5.01	4.13	0.0%	0 of 92	109
Apr to Jun 2025	4.66	0.77	4.88	4.10	0.0%	0 of 91	106
United States, Jan to Mar 2026	3.75	0.62	3.92	3.33	5.3%	0.5% of days
North Carolina, Jan to Mar 2026	3.65	0.53	3.82	3.25	8.0%	0.7% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.

Official wage estimates for North Carolina

Job	Median	Middle half	Employed
North Carolina, all employers
CNAs (nursing assistants)	$18.49	$17.28 to $21.08	64,010
LPNs and LVNs	$30.42	$28.50 to $33.51	18,010
Registered nurses	$40.56	$37.87 to $49.06	111,120
United States, nursing care facilities
CNAs (nursing assistants)	$20.67	$17.91 to $22.55	534,270
LPNs and LVNs	$33.86	$30.05 to $37.40	188,210
Registered nurses	$41.11	$37.85 to $47.68	142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

Measure	This home	North Carolina	US
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1	25.5	15.6	13.9
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1	0.2	0.7	0.8
Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1	2.0	2.3	1.6
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1	4.3	3.5	3.2
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1	0.0	1.4	1.6
Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1	30.7	18.3	14.1
Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1	6.4	5.5	4.6
Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1	3.4	14.0	15.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231	26.8	22.9	23.8
Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231	4.4	12.9	12.0
Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231	1.5	1.8	1.9
Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231	1.1	1.8	1.8

Owners and operators

Legal business name: LUTHERAN HOME AT TRINITY OAKS, INC.. CMS links this home to Lutheran Services Carolinas, a group of 9 nursing homes averaging 4.2 stars overall.

Name	Role	Type	Since
Goins, Ted	Managing control - governing body	Individual	04/30/2007
Herman, Richard	Managing control - governing body	Individual	06/01/2022
Maddry, Karen	Managing control - governing body	Individual	10/01/2004
Nelson, Douglas	Managing control - governing body	Individual	09/01/2022
Smith, Kesha	Corporate director	Individual	10/01/2012
Maddry, Karen	Corporate officer	Individual	04/01/1982
Nickerson, Kirby	Corporate officer	Individual	10/01/2012
Lsa Management, Inc.	Operational/managerial control	Organization	07/29/2004
Lutheran Home at Trinity Oaks Property Inc	Operational/managerial control	Organization	07/29/2004
Amin, Chetan	Operational/managerial control	Individual	10/01/2012
Cornelison, Tim	Operational/managerial control	Individual	06/02/2022
Goins, Ted	Operational/managerial control	Individual	04/30/2007
Nickerson, Kirby	Operational/managerial control	Individual	10/01/2012
Smith, Kesha	Operational/managerial control	Individual	10/01/2012
Lutheran Services for the Aging, Inc.	Trustee of the SNF	Organization	07/29/2004
Goins, Ted	Trustee of the SNF	Individual	10/01/2004
Herman, Richard	Trustee of the SNF	Individual	06/01/2021
Nelson, Douglas	Trustee of the SNF	Individual	09/01/2022
Lsa Management, Inc.	Adp of the SNF	Organization	04/14/2025
Lutheran Home at Trinity Oaks Property Inc	Adp of the SNF	Organization	04/25/2025
Amin, Chetan	Adp of the SNF	Individual	10/01/2012
Cornelison, Tim	Adp of the SNF	Individual	06/02/2022
Nickerson, Kirby	Adp of the SNF	Individual	10/01/2012
Smith, Kesha	Adp of the SNF	Individual	10/01/2012

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 3 problems in this area, most recently on February 24, 2025: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody."
How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 3 problems in this area, most recently on February 24, 2025: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 2 problems in this area, most recently on February 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."
How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 2 problems in this area, most recently on February 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."

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North Carolina contacts for a concern about a nursing home

These are the official offices in North Carolina. NursingHomeClear cannot take or act on complaints.

Inspections and complaints: NC Division of Health Service Regulation, Nursing Home Licensure and Certification Section, the state agency that inspects nursing homes for CMS and takes complaints about care.
Resident advocate: North Carolina Long-Term Care Ombudsman Program. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
State inspection reports: NC DHSR Regulated Facilities search (Statements of Deficiencies), where North Carolina publishes its own records on licensed homes.

Common questions

What is Trinity Oaks's Medicare star rating?: CMS rates Trinity Oaks 5 out of 5 stars overall, with 4 for health inspections, 5 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Trinity Oaks get at its last inspection?: 0 health deficiencies at the standard inspection on April 2, 2026. The North Carolina average is 4.7.
Has Trinity Oaks been fined?: CMS lists no fines in the last three years.
Does Trinity Oaks accept Medicaid?: It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Trinity Oaks?: CMS lists 24 owners and managers, and links the home to Lutheran Services Carolinas. Legal business name: LUTHERAN HOME AT TRINITY OAKS, INC..

Sources

Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
Owners: CMS Ownership. Penalties: CMS Penalties.
Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.