Trinity Elms
Clemmons, Forsyth County, North Carolina · CCN 345565 · Non-profit (Church related) · part of Lutheran Services Carolinas (9 facilities, chain average 4.2 stars)
CMS rates Trinity Elms 2 of 5 overall as of August 2026. 100 certified beds, 91 residents a day on average. 14 citations on record from the current inspection cycles, 2 at immediate jeopardy; 2 fines totalling $15,646.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★☆☆☆ 2 of 5 |
|---|---|
| Health inspections | ★★★☆☆ 3 of 5 |
| Staffing | ★★★★☆ 4 of 5 |
| Quality measures | ★☆☆☆☆ 1 of 5 |
| Quality: long-stay / short-stay | 1 / 1 of 5 |
Staffing
| Total nurse staffing | 4.96022 hours per resident per day |
|---|---|
| Registered nurses | 0.70382 hours per resident per day |
| Weekend total | 4.71286 hours per resident per day |
| Nursing staff turnover | 50.5% (registered nurses 66.7%) |
| Administrators who left | 1 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-03-19 complaint survey |
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 · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Past Non-Compliance 2026-02-04 |
| 2026-03-19 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-31 |
| 2026-03-19 | 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 · tag F0655 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-31 |
| 2026-03-19 | 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 · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-31 |
| 2026-03-19 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Past Non-Compliance 2026-02-04 |
| 2025-04-30 complaint survey |
Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-30 |
| 2025-01-17 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies · tag F0851 |
F No actual harm, with potential for more than minimal harm; widespread | Past Non-Compliance 2024-11-15 |
| 2025-01-17 | 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 · tag F0578 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-06 |
| 2025-01-17 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-06 |
| 2025-01-17 | 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 · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-20 |
| 2024-08-20 complaint survey |
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 · tag F0580 |
J Immediate jeopardy to resident health or safety; isolated | Past Non-Compliance 2024-08-01 |
| 2024-08-20 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
J Immediate jeopardy to resident health or safety; isolated | Past Non-Compliance 2024-07-24 |
| 2023-08-30 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-09-18 |
| 2023-08-30 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
B No actual harm, with potential for minimal harm; pattern | Deficient, Provider has plan of correction 2023-09-18 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2024-08-20 | Fine | $7,823 |
| 2024-08-20 | Fine | $7,823 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Lsa Elms Property, Inc. Organization | adp of the snf | — | 2025-03-16 |
| Lsa Management, Inc. Organization | adp of the snf | — | 2025-03-16 |
| Lsa Management, Inc. Organization | operational/managerial control | — | 2008-08-28 |
| Lutheran Services For The Aging, Inc. Organization | operational/managerial control | — | 2008-08-28 |
| Lutheran Services For The Aging, Inc. Organization | trustee of the snf | — | 2008-08-28 |
| Goins, Ted Individual | adp of the snf | — | 2004-10-01 |
| Mccoy, Cynthia Individual | adp of the snf | — | 2003-06-26 |
| Nickerson, Kirby Individual | adp of the snf | — | 2012-10-01 |
| Owens-Watterson, Dawn Individual | adp of the snf | — | 2023-05-03 |
| Smith, Kesha Individual | adp of the snf | — | 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 |
| Goins, Ted Individual | managing control - governing body | — | 2004-10-01 |
| Herman, Richard Individual | managing control - governing body | — | 2022-06-01 |
| Nelson, Douglas Individual | managing control - governing body | — | 2022-09-01 |
| 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 |
| Goins, Ted Individual | trustee of the snf | — | 2004-10-01 |
| Nelson, Douglas Individual | trustee of the snf | — | 2022-09-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Trinity Elms.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Forsyth County.