Trinity Elms
Clemmons, North Carolina · CCN 345565
11 surveys since 2015. The first finding at harm level was recorded in 2024.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 22
- Surveys
- 11
- Harm or worse
- 4
- Immediate jeopardyall corrected before survey
- 2
Findings at the most serious level CMS records. All were recorded as past non-compliance — corrected before the survey.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 100
- Ownership
- Non profit - Church related
- Chain
- LUTHERAN SERVICES CAROLINAS
- County
- Forsyth
- Medicare-certified since
- 2014
CMS ratings
- Overall
- 2
- Health inspection
- 3
- Staffing
- 4
- Quality measures
- 1
CMS’s own Five-Star ratings.
Compared with similar facilities
Not shown for this facility: too few citations in window (n=18, floor 20).
Last survey on record
Mar 19, 2026
235 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 4.96 | 4.62 |
| Registered-nurse hours per resident day | 0.70 | — |
| Annual nurse turnover | 50.5% | 41.3% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $15,646 across 2 penalties
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J214.3% | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D1071.4% | E— | F17.1% |
| No harm, potential for minimal | A— | B17.1% | C— |
Most frequently cited here
In CMS’s current monthly file.
- F5802×
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- F5781×
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.
- F6091×
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- F6411×
Ensure each resident receives an accurate assessment.
- F6551×
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
In the surveyor’s words
From the most serious findings on record at Trinity Elms, in the surveyor’s own words.
- Immediate jeopardy, isolatedF580Aug 20, 2024
Based on record review, observations, interviews with staff, Dermatologist, and Medical Director, the facility staff failed to notify medical provider of a change in condition for a nonverbal resident with a diagnosis of diabetes when new skin wounds were observed on 7/22/24. The Medical Director was notified on 7/23/24 and Resident #1 was sent to the Emergency Department (ED) on 07/23/24 and was diagnosed with deep partial thickness burns to the anterior (front) and medial thighs bilaterally as well as the mons pubis (fatty tissue that covers the pubic bone). […]
- Immediate jeopardy, isolatedF689Aug 20, 2024
Based on record review, observations, and interviews with staff, Hospital Case Manager, Plumbing Contractor, Dermatologist, and the Medical Director, the facility staff failed to supervise a severely cognitively impaired and nonverbal resident in the shower room. On 7/22/24 Nurse Aide (NA) #1 left Resident #1 unattended and naked on the shower bed with the water running on her body. When NA #1 returned to the shower spa, Resident #1 had a pool of water over her bilateral thighs and genital area. NA #1 took a washcloth to remove the puddle of water and noticed that Resident #1's top layer of skin on her bilateral upper thighs was peeling off. […]
- Actual harm, isolatedF684Aug 18, 2026
Based on record reviews, and staff, Nurse Practitioner and Medical Director interviews, the facility failed to ensure there was effective communication and assessments related to a resident's fall, which delayed medical evaluation and treatment. An X-ray of the right lower extremity completed on 5/25/26 revealed a supracondylar fracture in the distal femur (a break in the thigh bone just above the knee joint). The deficient practice occurred for 1 of 3 residents reviewed for accidents (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included history of falling and unsteadiness on feet, congestive heart failure, chronic kidney disease, and type II diabetes.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident… […]
- Actual harm, isolatedF689Aug 18, 2026
Based on record review and staff interviews, the facility failed to provide care in a safe manner. On 5/21/26 around 6:00AM Resident #1, who was ordered to utilize a mechanical sit to stand assist lift for transfer with the assistance of 2 staff, was being transferred from bed to chair by Nursing Aide (NA) #1, without assistance, via a stand pivot sit transfer. Resident #1 became weak when being transferred and the NA lowered Resident #1 to the floor. After Resident #1 was lowered to the floor, NA #1 had NA #2 assist her with picking Resident #1 up off of the floor and moved the resident to the bed. Then NA #1 and NA #2 transferred Resident #1 from the bed to the chair using another stand pivot sit transfer. On 5/25/26 Resident #1 reported pain in her right knee. […]
- No harm, potential for more than minimal, widespreadF851Jan 17, 2025
Based on record review and staff interviews, the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) related to Registered Nurse (RN) hours, licensed nursing coverage 24-hours per day. This was for 1 of 3 quarters reviewed for sufficient nurse staffing (Quarter 4 2024 July 1-September 30). Findings included: Review of the PBJ for Fiscal Year Quarter 4 2024 (July 1- September 30) revealed there were no Registered Nurse (RN) hours for 9/1/24, 9/4/24, 9/5/24, 9/6/24, 9/10/24, 9/11/24,9/12/24, 9/13/24, 9/14/24, 9/15/24, 9/16/24, 9/18/24, 9/19/24 9/23/24, 9/24/24 9/26/24, 9/27/24, 9/28/24, 9/29/24, and 9/30/24. […]
Read 20 findings in full →The most serious and the most recent: 20 of 22 on record.
Every survey on record
FindingsAt actual harm or above
- Aug 18, 2026Complaint2 findings · 2 harm
- Mar 19, 2026Standard and complaint5 findings
- Apr 30, 2025Complaint1 finding
- Jan 17, 2025Standard4 findings
- Aug 20, 2024Complaint2 findings · 2 harm
- Aug 30, 2023Standard and complaint2 findings
- Mar 31, 2022Standard2 findings
- Aug 8, 2018Standard1 finding
Show the 3 earlier surveys
- Nov 16, 2017Complaint1 finding
- Aug 25, 2017Standard1 finding
- Oct 29, 2015Standard1 finding
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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