Trinity Oaks

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

57.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 84 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 30.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 42 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.37 therapist hours per resident per day in 2026Q1 — more than 63% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 115 beds and averages 108.2 residents a day — about 94% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.30 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.93 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.70 hrs/resident/day on weekends vs 4.55 on weekdays — 19% thinner on weekends. RN hours go from 0.94 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 30% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.

• Potential for harm · E2025-02-24 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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). The findings included: An interview with Resident #8 on 2/17/25 at 2:27 PM revealed the shower room on the C-Hall where she resides was dirty and there was black mold visible on the walls. Resident #8 stated she did not like using the shower room because it was dirty, and she did not feel clean after her showers. An observation of the C-Hall shower room on 2/18/25 at 11:20 AM revealed there was a buildup of black grime observed around the shower fixtures, along the edges of the floor, and around areas on the wall where the paint was peeling. There was a buildup of black grime around a cabinet hanging on the wall and in the crevices around the cabinet doors. There was also a buildup of black grime observed on the feet of the shower chair and along the bottom of the shower curtain. An interview conducted with Housekeeper #1 on 2/18/25 at 12:30 PM revealed she was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-24 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). The findings included: Resident #16 was admitted to the facility on [DATE] with diagnoses which included anxiety, cognitive communication deficit, muscle weakness, dementia, and generalized osteoarthritis. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #16 was severely cognitively impaired and required extensive assistance transfers and toilet use. The MDS further revealed Resident #16 was not coded for any behaviors through the look back period. Review of Resident #16's care plan revised on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-24 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. The findings included: A review of the facility policy and procedure titled Abuse Investigation and Reporting for Senior Services, with a revised date of 04/26/22, read in part 1.) under Identification and Investigation if the person(s) observing or suspecting incidents of resident abuse, neglect, exploitation or misappropriation of property must report such knowledge or suspicion to the nursing supervisor or his/her department manager as soon as he or she is aware of an incident or potential incident. Read in part 2.) Under Protection while the investigation is pending,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-24 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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). The findings included: Review of the initial facility reported incident dated 01/18/24 at 5:30 PM revealed it was reported that a Nurse Aide (NA) #5 mistreated a resident during care. It was revealed Resident #16 showed no signs of physical or mental abuse found during the assessment on 1/18/24. A phone interview conducted with Nurse #3 on 02/20/25 at 1:25 PM revealed on 01/18/24 around 5:00 PM it was reported to her by Personal Care Assistant (PCA) #1 that NA #5 had put her hand over the resident's mouth during care and told the resident to be quiet. Nurse #3 indicated she notified the administrator immediately what NA #5 had alleged. An interview conducted with the Administrator on 02/20/25 at 1:55 PM revealed he completed the initial report to the State Agency. The Administrator further revealed on 01/18/24 he was notified by Nurse #3 that NA #5 had…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to provide a safe transfer for 1 of 6 residents (Resident #69) reviewed for accidents. The findings included: Resident #69 was admitted to the facility 1/07/25 with diagnoses including muscle weakness, abnormalities of gait and mobility, and mild cognitive impairment. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #69 was severely cognitively impaired and dependent on staff for transfers. The care plan dated 1/21/25 revealed Resident #69 required 2-person assistance for all transfers. An incident report dated 2/07/25 12:25 PM completed by Nurse #2 revealed Nurse Aide (NA) #1 was transferring Resident #69 from the wheelchair to a shower chair when Resident #69 was unable to support herself and NA #1 lowered her down to the floor. NA #1 was transferring Resident #69 without a second person and did not use a gait belt. Resident #69 was assessed, and no injuries were noted. A phone interview conducted with NA #1 on 2/19/25 at 2:38…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-02-24 · tag F0761 — failed to label and store drugs safely — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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). The findings included: 1. During wound care observation on 2/18/25 at 9:30 AM on the D hall, the treatment cart was observed to be in the hallway outside of room D5, unsecured. Residents were noted to be ambulating past the cart without any staff members present. Observation on 2/18/25 at 9:35 AM of the treatment cart revealed it consisted of three- 4 drawer plastic towers, two recycled bedside tabletops (one sitting on top of the plastic towers and one on the bottom) and it was held together by PVC (polyvinyl chloride) piping surrounding the perimeter. There was no locking mechanism on the cart. Observation of the items in the treatment cart drawers on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2023-10-26 · tag F0851 — widespread
  Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings included: The CMS submission report, PBJ Final File Validation Report for Fiscal Year Quarter 3,2023 (April 1 - June 30) was reviewed and indicated the facility reported excessively low weekend staffing and failed to have Licensed Nurse Coverage 24 hours per day on Sunday, 04/09/23, Saturday, 05/20/23, Sunday, 05/21/23, Sunday 06/04/23, and Sunday 06/18/23. Nurse staff timecards, daily nurse staff schedules, and posted nurse staff documents dated for 4/9/23, 5/20/23, 5/21/23, 6/4/23 and 6/18/23, were reviewed and revealed multiple licensed and unlicensed nurse staff were not recorded accurately or were omitted on the PBJ report (1705D) for the 3rd quarter of Fiscal year 2023. An interview conducted on 10/26/23 at 8:45 AM…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-10-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. The findings included: The Use by Date Storage Chart posted on the walk-in refrigerator, recorded All food items must be properly dated and labeled and must be stored in either containers with lids, foil/film wrappers, sealed food storage bags, or their original container. A continuous observation with the Assistant Dietary Manager (ADM) of the walk-in refrigerator, cook's reach in refrigerator, the freezer and the dry storage occurred on 10/23/23 from 10:25 AM until 11:15 AM and revealed the following concerns: 1a. The cook's reach in refrigerator was observed at 10:25 AM with the following concerns: - An opened four-pound container of pimento cheese did not record the date opened. 1b. The walk-in refrigerator…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-10-26 · tag F0814 — failed to dispose of garbage properly — pattern
  Dispose of garbage and refuse properly.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. The findings included: During a continuous observation with the Assistant Dietary Manager (ADM) on 10/26/23 from 09:45 AM until 10:00 AM of three commercial trash receptacles and one commercial trash compactor, the door of one commercial trash receptacle was observed open, the receptacle was odorous, with multiple flies observed and the trash inside the receptacle was exposed. Further observation of the grounds around the commercial trash receptacles and the commercial trash compactor included the following: - Multiple articles of trash and debris - One used blue glove, inverted. - Four empty cardboard boxes - One mattress - One broken broom - One white polyvinyl chloride pipe - Two storage carts, one filled with multiple empty plastic bottles. - A motorized wheelchair. - One empty storage bin - One storage bin filled with table linen. -…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-10-26 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings included: Resident #38 was admitted to the facility on 03/02/ 23. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had no cognitive impairment. An initial allegation report dated 08/14/23 at 8:45AM documented Resident #38 reported Nurse #11 spoke to her disrespectfully. Nurse #11 was suspended from the facility during the investigation. The 5- day investigative report dated 08/17/23 documented the facility investigation into the incident revealed the exchange between Nurse #11 and Resident #38 was inappropriate and disrespected the Resident. The Administrator interviewed Resident #38 on 08/14/23 and Resident #38 revealed Nurse #11 had been disrespectful and hurt her feelings. Resident #38 felt safe at the facility. Nurse #11 was terminated from…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to LUTHERAN SERVICES CAROLINAS — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 24 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NC