Trinity Elms
7449 Fair Oaks Drive, Clemmons, NC 27012 · CCN 345565
Ratings
- Overall
- ★★☆☆☆ 2
- Health inspection
- ★★★☆☆ 3
- Quality measures
- ★☆☆☆☆ 1
- Staffing
- ★★★★☆ 4
Facility
- Ownership type
- Non profit - Church related
- Certified beds
- 100
- Avg residents/day
- 85.7
- Phone
- 3367471153
Inspection history vs North Carolina & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | North Carolina avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-01-17 | 5 | 5.6 | 9.5 | -0.6 better |
| 2 | 2023-08-30 | 4 | 7.2 | 9.8 | -3.2 better |
| 3 | 2022-03-31 | 2 | 7.4 | 9.3 | -5.4 better |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Quality of life and care | 1 |
| Resident rights | 1 |
| Pharmacy service | 2 |
| Administration | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 4.28 | 46.3% |
| RN staffing (reported) | 0.63 | 73.3% |
| Total nurse staffing (adjusted) | 4.56 | — |
Fines & penalties
- Total fines
- $15,646
- Number of fines
- 2
- Number of penalties
- 2
- Payment denials
- 0
Chain
- Chain
- LUTHERAN SERVICES CAROLINAS
- Facilities in chain
- 9
- Chain avg overall
- 4.30 / 5
Inspection citations (11)2 immediate jeopardy
- DF0760Ensure that residents are free from significant medication errors.2025-04-30 · Health · corrected 2025-04-30
Potential for more than minimal harm
- DF0578Honor 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.2025-01-17 · Health · corrected 2025-02-06
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2025-01-17 · Health · corrected 2025-02-06
Potential for more than minimal harm
- DF0761Ensure 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.2025-01-17 · Health · corrected 2025-01-20
Potential for more than minimal harm
- FF0851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.2025-01-17 · Health · corrected 2024-11-15
Potential for more than minimal harm
- JF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-08-20 · Health · corrected 2024-08-01
Immediate jeopardy
- JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-08-20 · Health · corrected 2024-07-24
Immediate jeopardy
- BF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-08-30 · Health · corrected 2023-09-18
Potential for minimal harm
- DF0759Ensure medication error rates are not 5 percent or greater.2023-08-30 · Health · corrected 2023-09-18
Potential for more than minimal harm
- DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2022-03-31 · Health · corrected 2022-04-20
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2022-03-31 · Health · corrected 2022-04-20
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| LSA MANAGEMENT, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2008-08-28 |
| LUTHERAN SERVICES FOR THE AGING, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2008-08-28 |
| GOINS, TED | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2004-10-01 |
| MCCOY, CYNTHIA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2023-06-26 |
| OWENS-WATTERSON, DAWN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2023-05-03 |
| SMITH, KESHA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2012-10-01 |
| SMITH, KESHA | Individual | CORPORATE DIRECTOR | — | 2003-09-08 |
| MADDRY, KAREN | Individual | CORPORATE OFFICER | — | 2014-01-01 |
| NICKERSON, KIRBY | Individual | CORPORATE OFFICER | — | 2012-10-01 |
Other facilities in Clemmons
| Name | Overall | Beds |
|---|---|---|
| Cedar Hills Center for Nursing and Rehabilitation | ★☆☆☆☆ | 94 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.