D69

Trinity Elms

Grade D 69/100 composite score

Non profit - Church related

CMS Star Ratings

Overall
2/5
Health Insp.
3/5
Quality
1/5
Staffing
4/5
RN Staffing
Not rated

Certified Beds

100

Ownership

Non profit - Church related

Total Fines

$15,646

Last Survey

N/A

7449 Fair Oaks Drive, Clemmons, NC 27012
3367471153

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.67h
LPN
0.86h
CNA
3.04h
Total
4.56h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

LSA MANAGEMENT, INC.

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Aug 2008

LUTHERAN SERVICES FOR THE AGING, INC.

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Aug 2008

GOINS, TED

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Oct 2004

MCCOY, CYNTHIA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jun 2023

OWENS-WATTERSON, DAWN

IndividualOPERATIONAL/MANAGERIAL CONTROLSince May 2023

SMITH, KESHA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Oct 2012

SMITH, KESHA

IndividualCORPORATE DIRECTORSince Sep 2003

MADDRY, KAREN

IndividualCORPORATE OFFICERSince Jan 2014

NICKERSON, KIRBY

IndividualCORPORATE OFFICERSince Oct 2012

Penalties & Fines (2)

$15,646total fines
DateTypeDescriptionAmount
Aug 20, 2024Fine$7,823
Aug 20, 2024Fine$7,823

Health Inspection Deficiencies (11)

April 30, 2025Health1 deficiency
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Apr 30, 2025
January 17, 2025Health4 deficiencies
0578DMinimal harm, Isolated

Honor 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.

Resident Rights Deficiencies

Corrected Feb 6, 2025
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Feb 6, 2025
0761DMinimal harm, 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.

Pharmacy Service Deficiencies

Corrected Jan 20, 2025
0851FMinimal harm, Widespread

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

Administration Deficiencies

Corrected Nov 15, 2024
August 20, 2024Health2 deficiencies2 severe
0580JImmediate jeopardy, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Aug 1, 2024
0689JImmediate jeopardy, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jul 24, 2024
August 30, 2023Health2 deficiencies
0759DMinimal harm, Isolated

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Sep 18, 2023
0609BNo harm, Pattern

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Sep 18, 2023
March 31, 2022Health2 deficiencies
0690DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Apr 20, 2022
0812EMinimal harm, Pattern

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

Nutrition and Dietary Deficiencies

Corrected Apr 20, 2022

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Frequently Asked Questions

What is the CareGrader rating for Trinity Elms?

Trinity Elms in Clemmons, North Carolina has a CareGrader grade of D (Below Average), with a composite score of 68.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for Trinity Elms?

Trinity Elms has an overall CMS star rating of 2 out of 5, a health inspection rating of 3/5, and a staffing rating of 4/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does Trinity Elms have?

Trinity Elms has 11 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has Trinity Elms been fined?

Yes. Trinity Elms has $15,646 in total fines from CMS enforcement actions across 2 penalties.

How many beds does Trinity Elms have?

Trinity Elms has 100 certified beds with approximately 85 current residents (85% occupancy). The facility is located at 7449 Fair Oaks Drive, Clemmons, North Carolina 27012. It is a non profit - church related facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.