CMS PUBLIC RECORD · AUGUST 2026 RELEASERECORDS ARE ONE INPUT—NOT A PLACEMENT RECOMMENDATION
NURSING HOMELEDGERINSPECTIONS · OWNERSHIP · PENALTIES
CMS CCN 3455652026-08-01 PROCESSING DATE

NURSING HOME PUBLIC RECORD

Trinity Elms

CMS lists this provider in Clemmons, NC, with 100 certified beds, an overall rating of 2/5, and 23 citation rows in the current August 2026 release.

7449 Fair Oaks Drive · Clemmons, NC 27012 · Forsyth County

CMS OVERALL RATING★★☆☆☆2/5CMS field—not our score or recommendation
Certified beds100CMS provider file
Recent citation rows23current CMS citation release
Penalty rows2current CMS penalties file
Read this record carefully.

The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.

01 / INSPECTION LEDGER

Trinity Elms survey cycles in this release

CMS supplies 3 survey-cycle rows for Trinity Elms in this release; health and fire inspection dates remain separate.

CycleHealth dateHealth deficienciesFire dateFire deficiencies
Cycle 12026-03-1952026-03-192
Cycle 22025-01-1772025-01-174
Cycle 32023-08-3022023-08-303
02 / CITATION DETAIL

Trinity Elms citations in the current release

CMS reports 23 citation rows, including 2 with G–L codes and 2 with J–L codes.

2 rows carry G–L scope/severity codes; 2 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.

2026-03-19 · HEALTHF0580Severity D · isolated; potential for more than minimal harm

Resident Rights Deficiencies

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

Correction field: Past Non-Compliance · 2026-02-04 · complaint
2026-03-19 · HEALTHF0641Severity D · isolated; potential for more than minimal harm

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Correction field: Deficient, Provider has date of correction · 2026-03-31
2026-03-19 · HEALTHF0655Severity D · isolated; potential for more than minimal harm

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Correction field: Deficient, Provider has date of correction · 2026-03-31
2026-03-19 · HEALTHF0656Severity D · isolated; potential for more than minimal harm

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Correction field: Deficient, Provider has date of correction · 2026-03-31
2026-03-19 · HEALTHF0684Severity D · isolated; potential for more than minimal harm

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Correction field: Past Non-Compliance · 2026-02-04 · complaint
2026-03-19 · FIREK0321Severity D · isolated; potential for more than minimal harm

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Correction field: Deficient, Provider has date of correction · 2026-06-27
2026-03-19 · FIREK0324Severity D · isolated; potential for more than minimal harm

Smoke Deficiencies

Provide properly protected cooking facilities.

Correction field: Deficient, Provider has date of correction · 2026-06-27
2025-04-30 · HEALTHF0760Severity D · isolated; potential for more than minimal harm

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Correction field: Deficient, Provider has date of correction · 2025-04-30 · complaint
2025-01-17 · HEALTHF0578Severity D · isolated; potential for more than minimal harm

Resident Rights Deficiencies

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.

Correction field: Deficient, Provider has date of correction · 2025-02-06
2025-01-17 · HEALTHF0695Severity D · isolated; potential for more than minimal harm

Quality of Life and Care Deficiencies

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

Correction field: Deficient, Provider has date of correction · 2025-02-06
2025-01-17 · HEALTHF0761Severity D · isolated; potential for more than minimal harm

Pharmacy Service Deficiencies

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.

Correction field: Deficient, Provider has date of correction · 2025-01-20
2025-01-17 · HEALTHF0851Severity F · widespread; potential for more than minimal harm

Administration Deficiencies

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

Correction field: Past Non-Compliance · 2024-11-15
2025-01-17 · FIREK0222Severity D · isolated; potential for more than minimal harm

Egress Deficiencies

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.

Correction field: Deficient, Provider has date of correction · 2025-05-02
2025-01-17 · FIREK0281Severity D · isolated; potential for more than minimal harm

Egress Deficiencies

Install proper backup exit lighting.

Correction field: Deficient, Provider has date of correction · 2025-05-02
2025-01-17 · FIREK0353Severity D · isolated; potential for more than minimal harm

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Correction field: Deficient, Provider has date of correction · 2025-05-02
2025-01-17 · FIREK0918Severity D · isolated; potential for more than minimal harm

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Correction field: Deficient, Provider has date of correction · 2025-05-02
2024-08-20 · HEALTHF0580Severity J · isolated immediate jeopardy

Resident Rights Deficiencies

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

Correction field: Past Non-Compliance · 2024-08-01 · complaint
2024-08-20 · HEALTHF0689Severity J · isolated immediate jeopardy

Quality of Life and Care Deficiencies

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

Correction field: Past Non-Compliance · 2024-07-24 · complaint
2023-08-30 · HEALTHF0609Severity B · pattern; potential for minimal harm

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Correction field: Deficient, Provider has plan of correction · 2023-09-18 · complaint
2023-08-30 · HEALTHF0759Severity D · isolated; potential for more than minimal harm

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Correction field: Deficient, Provider has date of correction · 2023-09-18
2023-08-30 · FIREK0353Severity D · isolated; potential for more than minimal harm

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Correction field: Deficient, Provider has date of correction · 2023-11-11
2023-08-30 · FIREK0363Severity C · widespread; potential for minimal harm

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Correction field: Deficient, Provider has date of correction · 2023-11-11
2023-08-30 · FIREK0918Severity D · isolated; potential for more than minimal harm

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Correction field: Deficient, Provider has date of correction · 2023-11-11
03 / ENFORCEMENT FILE

CMS penalties reported for Trinity Elms

The August 2026 file contains 2 penalty rows and $15,646 in listed fines for this provider record.

Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.

DateTypeFine amountPayment-denial days
2024-08-20Fine$7,8230
2024-08-20Fine$7,8230
04 / OWNERSHIP DISCLOSURES

Ownership disclosures for Trinity Elms

CMS matched 22 ownership disclosure rows to Trinity Elms; names and roles are reported fields, not independently verified identities.

  • GOINS, TEDIndividual · MANAGING CONTROL - GOVERNING BODY
    NOT APPLICABLE · since 10/01/2004
  • HERMAN, RICHARDIndividual · MANAGING CONTROL - GOVERNING BODY
    NOT APPLICABLE · since 06/01/2022
  • NELSON, DOUGLASIndividual · MANAGING CONTROL - GOVERNING BODY
    NOT APPLICABLE · since 09/01/2022
  • SMITH, KESHAIndividual · CORPORATE DIRECTOR
    NOT APPLICABLE · since 09/08/2003
  • MADDRY, KARENIndividual · CORPORATE OFFICER
    NOT APPLICABLE · since 01/01/2014
  • NICKERSON, KIRBYIndividual · CORPORATE OFFICER
    NOT APPLICABLE · since 10/01/2012
  • LSA MANAGEMENT, INC.Organization · OPERATIONAL/MANAGERIAL CONTROL
    NOT APPLICABLE · since 08/28/2008
  • LUTHERAN SERVICES FOR THE AGING, INC.Organization · OPERATIONAL/MANAGERIAL CONTROL
    NOT APPLICABLE · since 08/28/2008
  • GOINS, TEDIndividual · OPERATIONAL/MANAGERIAL CONTROL
    NOT APPLICABLE · since 10/01/2004
  • MCCOY, CYNTHIAIndividual · OPERATIONAL/MANAGERIAL CONTROL
    NOT APPLICABLE · since 06/26/2023
  • OWENS-WATTERSON, DAWNIndividual · OPERATIONAL/MANAGERIAL CONTROL
    NOT APPLICABLE · since 05/03/2023
  • SMITH, KESHAIndividual · OPERATIONAL/MANAGERIAL CONTROL
    NOT APPLICABLE · since 10/01/2012
  • LUTHERAN SERVICES FOR THE AGING, INC.Organization · TRUSTEE OF THE SNF
    NOT APPLICABLE · since 08/28/2008
  • GOINS, TEDIndividual · TRUSTEE OF THE SNF
    NOT APPLICABLE · since 10/01/2004
  • NELSON, DOUGLASIndividual · TRUSTEE OF THE SNF
    NOT APPLICABLE · since 09/01/2022
  • LSA ELMS PROPERTY, INCOrganization · ADP OF THE SNF
    NOT APPLICABLE · since 03/16/2025
  • LSA MANAGEMENT, INC.Organization · ADP OF THE SNF
    NOT APPLICABLE · since 03/16/2025
  • GOINS, TEDIndividual · ADP OF THE SNF
    NOT APPLICABLE · since 10/01/2004

Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.

05 / CMS STAFFING FIELDS

Staffing hours and turnover for Trinity Elms

CMS reports 4.96 total nurse hours and 0.70 RN hours per resident day for this provider.

Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.

Total nurse hours4.96per resident day
RN hours0.70per resident day
Weekend nurse hours4.71per resident day
Staff turnover50.5%CMS reported field
06 / LOCAL RECORDS

Facilities published near Trinity Elms

The local peer set contains 1 other published facility record near Clemmons, NC, with separate bed, rating, and citation-row fields.

Open the Clemmons ledger →
BEFORE A CARE DECISION

Verify the current record and visit in person.

Use this ledger to frame questions—not to choose care on its own. Recheck Medicare Care Compare, contact the state survey agency and long-term care ombudsman, and ask the facility about anything you find.