Nursing homeActive
Trinity Elms
7449 Fair Oaks Drive, Clemmons, NC 270123367471153100 certified beds · 91 residentsNon profit - Church relatedMedicare and Medicaid
Surveys on file
5
since 2023
Deficiencies
14
● 1● 11● 2
Penalties · 3 yrs
$15,646
2 fines
Last survey
2026-03-19
Standard
CMS overall
2 / 5
stars as published by CMS
CMS overall 2/5
Health 3
Staffing 4
Quality 1
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · North Carolina Division of Health Service Regulation · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-03-19 | Standard | 050 | CMS-2567 (Care Compare) | — |
| 2025-04-30 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-01-17 | Standard | 040 | CMS-2567 (Care Compare) | — |
| 2024-08-20 | Complaint | 002 | CMS-2567 (Care Compare) | — |
| 2023-08-30 | Standard | 110 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · North Carolina Division of Health Service Regulation publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-04Record 345565-20260319-F580
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 345565-20260319-F641
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 345565-20260319-F655
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 345565-20260319-F656
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-04Record 345565-20260319-F684
F760Ensure that residents are free from significant medication errors.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-30Record 345565-20250430-F760
F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-06Record 345565-20250117-F578
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-06Record 345565-20250117-F695
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-20Record 345565-20250117-F761
F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-11-15Record 345565-20250117-F851
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity JHarm
Dignity & rights
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-08-01Record 345565-20240820-F580
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-07-24Record 345565-20240820-F689
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-18Record 345565-20230830-F759
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity BPaperwork
Abuse & neglect
Pattern; potential for minimal harm.Corrected 2023-09-18Record 345565-20230830-F609
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2024-08-20 | Civil money penalty | $7,823 | CMS · Penalties |
| 2024-08-20 | Civil money penalty | $7,823 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.70
Facility
North Carolina
National
North Carolina 0.61 · National 0.69
Total nurse hours per resident day4.96
Facility
North Carolina
National
North Carolina 3.83 · National 3.86
Weekend total nurse hours4.71
Facility
North Carolina
National
North Carolina 3.40 · National 3.42
Total nursing staff turnover51%
Facility
North Carolina
National
North Carolina 49% · National 46%
Registered nurse turnover67%
Facility
North Carolina
National
North Carolina 46% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | North Carolina | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 7.4% | 5.5% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 4.1% | 3.5% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 16.7% | 14.0% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 2.1% | 2.3% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 27.8% | 15.6% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 10.0% | 7.2% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 19.6% | 21.3% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Goins, Ted Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Lsa Management, Inc. Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Lutheran Services For The Aging, Inc. Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Mccoy, Cynthia Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Owens-Watterson, Dawn Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Smith, Kesha Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Goins, Ted Individual | TRUSTEE OF THE SNF | NOT APPLICABLE | — | — |
| Goins, Ted Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Goins, Ted Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Herman, Richard Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Lsa Elms Property, Inc Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Lsa Management, Inc. Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Lutheran Services For The Aging, Inc. Organization | TRUSTEE OF THE SNF | NOT APPLICABLE | — | — |
| Maddry, Karen Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Mccoy, Cynthia Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Nelson, Douglas Individual | TRUSTEE OF THE SNF | NOT APPLICABLE | — | — |
| Nelson, Douglas Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Nickerson, Kirby Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Nickerson, Kirby Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Owens-Watterson, Dawn Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Smith, Kesha Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Smith, Kesha Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
Part of a chain
Lutheran Services Carolinas — 9 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or North Carolina.
No county cost figures on file for Forsyth.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Cedar Hills Center for Nursing and Rehabilitation Clemmons | 0.9 mi | 2026-06-26 | 3521 |
| Bermuda Village Retirement Center Bermuda Run | 2.4 mi | 2026-06-11 | 2150 |
| Bermuda Commons Nursing and Rehabilitation Center Advance | 2.5 mi | 2026-04-29 | 2172 |
| Homestead Hills Winston-Salem | 6.1 mi | 2026-07-01 | 011 |
| Silas Creek Rehabilitation Center Winston Salem | 6.9 mi | 2026-06-12 | 120 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |