| Trinity Elms | |
| 7449 Fair Oaks Drive, Clemmons, North Carolina 27012 | |
| (336) 747-1153 | |
| Name | Trinity Elms |
|---|---|
| Location | 7449 Fair Oaks Drive, Clemmons, North Carolina |
| Certified By | Medicare and Medicaid |
| No. of Certified Beds | 100 |
| Occupancy Rate | 90.8% |
| Medicare ID (CCN) | 345565 |
| Legal Business Name | Lutheran Home - Forsyth County, Inc. |
| Ownership Type | Non Profit - Church Related |
| Chain | Lutheran Services Carolinas (9 nursing homes) |
| Chain Average Overall Rating | 4.2 out of 5 |
| NPI Number | 1912323635 |
| Match | Confirmed listed in Medicare enrollment records |
| Organization Name | Lutheran Home - Forsyth County, Inc. |
| Doing Business As | Trinity Elms |
| Address | 7449 Fair Oaks Drive, Clemmons, NC 27012 |
| Phone Number | 704-637-2870 |
| Ratings from Surveys (Inspections): | |
| Ratings from Quality Measures: | |
| Ratings from Staffing Data: | |
| Overall Rating: |
|---|
| Staffing Measure | Provider | National Avg. |
|---|---|---|
| Total nurse staff hours per resident per day | 4.96 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.7 | 0.69 |
| Licensed practical nurse (LPN) hours per resident per day | 0.8 | 0.86 |
| Nurse aide hours per resident per day | 3.46 | 2.32 |
| Total nurse staff hours per resident per day on the weekend | 4.71 | 3.42 |
| RN hours per resident per day on the weekend | 0.69 | 0.48 |
| Physical therapist hours per resident per day | 0.12 | 0.07 |
| Total nursing staff turnover | 50.5% | 45.8% |
| Registered nurse turnover | 66.7% | 42.9% |
| Number of administrators who have left the nursing home | 1 | 0.5 |
| Cited for abuse, neglect or exploitation of residents (Care Compare abuse icon) | No |
| Number of Fines | 2 |
| Total Amount of Fines in Dollars | $15,646 |
| Number of Payment Denials | 0 |
| Total Number of Penalties | 2 |
| Date | Deficiency | Harm Level | Status |
|---|---|---|---|
| Mar 19, 2026 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. F0580, Resident Rights, Standard inspection, Complaint inspection | Potential for harm, isolated | Past non-compliance (already corrected) |
| Mar 19, 2026 | Ensure each resident receives an accurate assessment. F0641, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Mar 31, 2026 |
| Mar 19, 2026 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted F0655, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Mar 31, 2026 |
| Mar 19, 2026 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Mar 31, 2026 |
| Mar 19, 2026 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684, Quality of Life and Care, Standard inspection, Complaint inspection | Potential for harm, isolated | Past non-compliance (already corrected) |
| Apr 30, 2025 | Ensure that residents are free from significant medication errors. F0760, Pharmacy Service, Complaint inspection | Potential for harm, isolated | Corrected by Apr 30, 2025 |
| Jan 17, 2025 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. F0851, Administration, Standard inspection | Potential for harm, widespread | Past non-compliance (already corrected) |
| Jan 17, 2025 | 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. F0578, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Feb 6, 2025 |
| Jan 17, 2025 | Provide safe and appropriate respiratory care for a resident when needed. F0695, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Feb 6, 2025 |
| Jan 17, 2025 | 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. F0761, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Jan 20, 2025 |
| Aug 20, 2024 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. F0580, Resident Rights, Complaint inspection | Immediate jeopardy, isolated | Past non-compliance (already corrected) |
| Aug 20, 2024 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Complaint inspection | Immediate jeopardy, isolated | Past non-compliance (already corrected) |
| Aug 30, 2023 | Ensure medication error rates are not 5 percent or greater. F0759, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Sep 18, 2023 |
| Aug 30, 2023 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609, Freedom from Abuse, Neglect, and Exploitation, Standard inspection, Complaint inspection | Minimal harm potential, pattern | Plan of correction |
| Quality Measure | Provider | National Avg. |
|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.83 | 13.87 |
| Percentage of long-stay residents who lose too much weight | 10 | 5.19 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.47 | 0.82 |
| Percentage of long-stay residents with a urinary tract infection | 2.1 | 1.59 |
| Percentage of long-stay residents who have depressive symptoms | 0.77 | 12.8 |
| Percentage of long-stay residents who were physically restrained | 0 | 0.13 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.14 | 3.23 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.93 | 93.55 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.37 | 82.04 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.33 | 1.56 |
| Percentage of long-stay residents whose ability to walk independently worsened | 44.31 | 14.07 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.61 | 19.52 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100 | 95.46 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.1 | 79.75 |
| Percentage of long-stay residents with pressure ulcers | 7.43 | 4.62 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.65 | 19.01 |
| Percentage of long-stay residents who received an antipsychotic medication | 16.74 | 15.38 |
Cedar Hills Center for Nursing and Rehabilitation Location: 3905 Clemmons Road, Clemmons, North Carolina 27012 Phone: (336) 766-9158 |