Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Trinity Oaks during CMS and state inspections, most recent first.
A facility failed to maintain a clean and safe environment in a shower room, as reported by a resident and confirmed by observations. Black grime was found around fixtures, on the floor, and on equipment. Housekeeping staff inconsistently followed cleaning schedules, and the Director of Housekeeping acknowledged the need for cleaning and monitoring. The Administrator was unaware of the issues.
A resident was subjected to inappropriate behavior by a NA during incontinence care, where the NA placed her hand over the resident's mouth and spoke harshly. The PCA present did not intervene or report the incident immediately, allowing the NA to continue working, which violated the facility's abuse reporting policies.
A facility failed to include allegations of abuse in its initial report to the State Agency. A nurse aide was reported to have mistreated a resident by placing a hand over the resident's mouth and telling them to be quiet. This was reported by a PCA to a nurse, who informed the administrator. Despite this, the administrator did not include the allegations in the report, citing conflicting staff statements. The resident showed no signs of abuse during an assessment.
The facility failed to secure a treatment cart, leaving it unattended and unlocked in a hallway, and did not properly manage medication storage on a Unit-B cart, where loose pills and unlabeled medications were found. The Wound Nurse used the unsecured cart daily, and the DON was unaware of the issue. The Medication Aide and Nurse confirmed responsibilities for cart maintenance, but deficiencies persisted.
A cognitively impaired resident was subjected to inappropriate behavior by a nurse aide during care, where the aide placed her hand over the resident's mouth and instructed them to stop whining. The incident was witnessed by a PCA, who reported the aggressive behavior. Despite an investigation, the facility did not substantiate the abuse claim due to conflicting accounts and lack of physical evidence.
A resident with cognitive impairment and mobility issues required two-person assistance for transfers. However, a nurse aide attempted to transfer the resident alone, resulting in the resident being lowered to the floor without injury. The aide felt rushed and did not seek available assistance, contrary to the care plan requirements.
Failure to Maintain Clean Shower Room
Penalty
Summary
The facility failed to maintain a clean and safe environment in the C-Hall shower room, as observed during a survey. A resident reported that the shower room was dirty and had visible black mold on the walls, which made her uncomfortable using it. Observations confirmed a buildup of black grime around the shower fixtures, floor edges, and areas where the paint was peeling. Additional grime was noted on a cabinet, the feet of the shower chair, and the bottom of the shower curtain. Interviews with housekeeping staff revealed inconsistencies in the cleaning schedule and responsibilities. Housekeeper #1, who was assigned to clean the C-Hall shower room, did not clean it on several scheduled days and was unable to recall the reasons. Housekeeper #2, who covered for Housekeeper #1, was unable to clean the shower room due to its use by residents. The Director of Housekeeping confirmed that the areas with grime needed cleaning and that Housekeeper #1 was responsible for monitoring and reporting the condition of the shower room items. The Administrator was unaware of the issues and stated that housekeepers should report equipment in poor condition.
Failure to Follow Abuse Reporting Policies
Penalty
Summary
The facility failed to adhere to its abuse policies regarding identification, protection, and reporting, as evidenced by an incident involving a resident who was subjected to inappropriate behavior by a staff member. During incontinence care, a Nurse Aide (NA) placed her hand over the resident's mouth and spoke harshly to the resident, who was cognitively impaired and unable to understand the situation. The Personal Care Assistant (PCA) present did not intervene or report the incident immediately, allowing the NA to continue working the rest of her shift, potentially putting other residents at risk. The facility's policy requires immediate reporting of suspected abuse to a nursing supervisor or department manager, and suspension of the accused individual pending investigation. However, the PCA delayed reporting the incident until several hours later, and the NA was not suspended until the administrator was informed. The resident involved was known to become upset during care, and the PCA's failure to act promptly contributed to the deficiency in following the facility's abuse prevention policies.
Failure to Report Alleged Abuse in Initial State Report
Penalty
Summary
The facility failed to include reported allegations of abuse in the initial report to the State Agency. The incident involved a nurse aide allegedly mistreating a resident during care by placing a hand over the resident's mouth and instructing them to be quiet. This allegation was reported to a nurse by a personal care assistant and subsequently communicated to the facility administrator. Despite being informed of the incident, the administrator did not include the specific allegations in the initial report to the State Agency, citing conflicting staff statements as the reason for omission. The resident involved showed no signs of physical or mental abuse during an assessment conducted on the same day as the reported incident.
Medication and Treatment Cart Security and Labeling Deficiencies
Penalty
Summary
The facility failed to secure medicated treatment supplies in a locked treatment cart, as observed during a wound care session. The treatment cart was left unsecured in the hallway outside a resident's room, with residents walking past it without any staff supervision. The cart, constructed from plastic towers and recycled tabletops, lacked a locking mechanism. The Wound Nurse, who had been using the cart daily, stated that she could partially lock it but typically left it outside residents' rooms during the day. The Director of Nursing (DON) was unaware of the unsecured cart and stated that all treatment carts should be secured when not attended by staff. Additionally, the facility failed to properly manage medication storage on the Unit-B medication cart. Loose pills of various shapes and sizes were found in the cart drawers, and two green caplets were placed in an unlabeled clear white bag. The Medication Aide (MA) indicated that medications were sometimes placed in such bags for residents being discharged. Nurse #1 confirmed that each nurse was responsible for cleaning and organizing the medication cart, ensuring all medications were labeled. The DON reiterated that nurses should clean the carts, discard loose pills, and ensure medications are administered immediately after removal from their original containers.
Failure to Protect Resident from Staff Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse by staff. During an incident involving a cognitively impaired resident, a nurse aide (NA) placed her hand over the resident's mouth and instructed the resident to stop whining. This action was taken while the resident was agitated and crying during incontinence care. The resident, who was severely cognitively impaired and had a history of anxiety and dementia, was unable to communicate effectively and was often resistive to care. The incident was reported by a personal care assistant (PCA) who witnessed the NA's actions. The PCA described the NA's behavior as aggressive, noting that the resident appeared petrified during the encounter. Despite the NA's claim that she only tapped the resident's mouth, the PCA reported that the NA held her hand over the resident's mouth for nearly 30 seconds. The facility conducted an investigation, including interviews and assessments, but found no physical or mental signs of abuse on the resident. The Director of Nursing (DON) and the Administrator were informed of the incident, and the NA was eventually let go. However, the facility did not substantiate the abuse claim due to conflicting staff accounts and the absence of physical evidence. The responsible party for the resident was not notified of the incident, and the facility concluded that the incident did not constitute abuse, despite the inappropriate actions taken by the NA.
Unsafe Transfer of Resident Due to Inadequate Assistance
Penalty
Summary
The facility failed to provide a safe transfer for Resident #69, who was admitted with diagnoses including muscle weakness, abnormalities of gait and mobility, and mild cognitive impairment. The resident was severely cognitively impaired and dependent on staff for transfers, requiring two-person assistance as per the care plan. On February 7, 2025, Nurse Aide (NA) #1 attempted to transfer Resident #69 from a wheelchair to a shower chair without a second person and did not use a gait belt. During the transfer, Resident #69 was unable to support herself, and NA #1 lowered her to the floor. Although no injuries were noted, the transfer was conducted unsafely, contrary to the care plan requirements. NA #1 admitted to feeling rushed and attempted the transfer alone because she could not find assistance, despite Nurse #2 and Nurse #3 being available at the nurse's station. Both nurses confirmed that they were available to help but were not asked by NA #1. The Director of Nursing and the Administrator confirmed that Resident #69 required two-person assistance for transfers, and NA #1 acknowledged she was aware of this requirement. The incident highlights a failure to adhere to the care plan and ensure adequate supervision and assistance during resident transfers.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Salisbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Piedmont Health & Rehab Center | 1.8 mi | ★★★★★ | 6 | 1 |
| Nc State Veterans Home - Salisbury | 2.3 mi | ★★★★★ | 12 | 1 |
| Autumn Care Of Salisbury | 2.4 mi | ★★★★★ | 6 | 0 |
| Liberty Commons Nsg And Rehab Ctr Of Rowan County | 2.9 mi | ★★★★★ | 5 | 0 |
| Salisbury Rehabilitation And Nursing Center | 3 mi | ★★★★★ | 17 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.