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Trinity Elms
7449 Fair Oaks Drive, Clemmons, NC 27012 · CMS Certification Number (CCN) 345565
At a glance
- CMS overall rating
- ★★☆☆☆ 2 of 5
- Health inspection citations
- 14 in the last 3 inspection cycles (2 immediate jeopardy, 0 actual harm, 5 from complaints)
- Fire safety citations
- 9
- Fines (last 3 years)
- 2 fines, total $15,646
- Payment denials
- 0
- Most recent standard inspection
- March 19, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Overall | ★★☆☆☆ 2 of 5 | 2.9 | 3 |
| Health inspections | ★★★☆☆ 3 of 5 | 2.9 | 2.8 |
| Staffing | ★★★★☆ 4 of 5 | 2.7 | 2.9 |
| Quality measures | ★☆☆☆☆ 1 of 5 | 3.3 | 3.6 |
| Long-stay quality | ★☆☆☆☆ 1 of 5 | Not published | Not published |
| Short-stay quality | ★☆☆☆☆ 1 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | March 19, 2026 | 5 | 5 | 2 |
| Cycle 2 | January 17, 2025 | 7 | 4 | 3 |
CMS weighted health inspection score: 33 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
14 health citations across 5 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
March 19, 2026: 5 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Standard + Complaint | Past Non-Compliance Corrected 02/04/2026 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/31/2026 |
| D | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/31/2026 |
| D | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/31/2026 |
| D | F-0580 | 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 | Standard + Complaint | Past Non-Compliance Corrected 02/04/2026 |
April 30, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/30/2025 |
January 17, 2025: 4 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| F | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies | Standard | Past Non-Compliance Corrected 11/15/2024 |
| D | F-0761 | 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 | Standard | Deficient, Provider has date of correction Corrected 01/20/2025 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/06/2025 |
| D | F-0578 | 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 | Standard | Deficient, Provider has date of correction Corrected 02/06/2025 |
August 20, 2024: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Past Non-Compliance Corrected 07/24/2024 |
| J | F-0580 | 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 | Complaint | Past Non-Compliance Corrected 08/01/2024 |
August 30, 2023: 2 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/18/2023 |
| B | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has plan of correction Corrected 09/18/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
9 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 03/19/2026 | D | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/27/2026 |
| 03/19/2026 | D | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/27/2026 |
| 01/17/2025 | D | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 05/02/2025 |
| 01/17/2025 | D | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/02/2025 |
| 01/17/2025 | D | K-0281 | Install proper backup exit lighting. Egress Deficiencies | Deficient, Provider has date of correction Corrected 05/02/2025 |
| 01/17/2025 | D | K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Egress Deficiencies | Deficient, Provider has date of correction Corrected 05/02/2025 |
| 08/30/2023 | D | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 11/11/2023 |
| 08/30/2023 | C | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 11/11/2023 |
| 08/30/2023 | D | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 11/11/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| August 20, 2024 | Fine | $7,823 | — |
| August 20, 2024 | Fine | $7,823 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 4.96 | 3.85 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.7 | 0.62 | 0.69 |
| LPN/LVN hours per resident per day | 0.8 | Not published | Not published |
| Nurse aide hours per resident per day | 3.46 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 4.71 | Not published | Not published |
| RN hours per resident per day, weekends | 0.69 | Not published | Not published |
| Total nursing staff turnover (%) | 50.5 | 49 | 45.8 |
| Registered nurse turnover (%) | 66.7 | Not published | Not published |
| Administrators who have left | 1 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Lutheran Home - Forsyth County, INC.
- Ownership type
- Non profit - Church related
- Chain
- Lutheran Services Carolinas (9 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 100
- Average residents per day
- 90.8
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- Yes
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- November 13, 2014
- County/parish
- Forsyth
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
22 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| GOINS, TED | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HERMAN, RICHARD | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NELSON, DOUGLAS | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SMITH, KESHA | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MADDRY, KAREN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NICKERSON, KIRBY | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LSA MANAGEMENT, INC. | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| LUTHERAN SERVICES FOR THE AGING, INC. | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| GOINS, TED | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCCOY, CYNTHIA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| OWENS-WATTERSON, DAWN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SMITH, KESHA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LUTHERAN SERVICES FOR THE AGING, INC. | TRUSTEE OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| GOINS, TED | TRUSTEE OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NELSON, DOUGLAS | TRUSTEE OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LSA ELMS PROPERTY, INC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| LSA MANAGEMENT, INC. | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| GOINS, TED | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCCOY, CYNTHIA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NICKERSON, KIRBY | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| OWENS-WATTERSON, DAWN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SMITH, KESHA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Trinity Elms. Full inspection reports, quality measures and staffing.
- DHSR Complaint Intake Unit: File a Complaint. The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.