Cycle 1
Health 2025-01-17 · Fire 2025-01-17
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Clemmons, NC
Trinity Elms
2-star overall rating with 3-star inspections with $15,646 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
7449 Fair Oaks Drive, Clemmons, NC
(336) 747-1153
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
86
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lutheran Services Carolinas
Operator or chain grouping
Approved since
2014-11-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 4 overall / 4 health / 5 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.63
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.85
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.28
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
4.00
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
4.56
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,649
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9840
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.87% · Performance 21.52% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.01
Baseline 5.55% · Performance 6.94% · Measure score 3.01 · Achievement 3.01 · Improvement 0
Total nurse turnover
4.18
Baseline 50.62% · Performance 46.61% · Measure score 4.18 · Achievement 4.18 · Improvement 1.06
Adjusted total nurse staffing
3.26
Baseline 3.30 hours · Performance 4.01 hours · Measure score 3.26 · Achievement 3.26 · Improvement 2.34
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.48% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 174 · Observed rate 10.34% · Lower 95% interval 8.51% |
| Discharge to community | 46.78% |
50.57%
3.8 pts worse
|
No Different than the National Rate · Eligible stays 174 · Observed rate 45.4% · Lower 95% interval 38.97% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 114 · Denominator 114 |
| Falls with major injury | 0.88% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 114 |
| Discharge self-care score | 50.59% |
53.69%
3.1 pts worse
|
Numerator 43 · Denominator 85 |
| Discharge mobility score | 52.94% |
50.94%
2 pts better
|
Numerator 45 · Denominator 85 |
| Pressure ulcers or injuries, new or worsened | 3.51% |
2.29%
1.2 pts worse
|
Numerator 4 · Denominator 114 · Adjusted rate 3.51% |
| Healthcare-associated infections requiring hospitalization | 6.94% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 116 · Observed rate 5.17% · Lower 95% interval 4.65% |
| Staff COVID-19 vaccination coverage | 6.49% |
8.2%
1.7 pts worse
|
Numerator 10 · Denominator 154 |
| Staff flu vaccination coverage | 24.68% |
42%
17.3 pts worse
|
Numerator 38 · Denominator 154 |
| Discharge function score | 48.24% |
56.45%
8.2 pts worse
|
Numerator 41 · Denominator 85 |
| Transfer of health information to provider | 97.83% |
95.95%
1.9 pts better
|
Numerator 90 · Denominator 92 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 30.3% |
25.2%
5.1 pts better
|
Numerator 20 · Denominator 66 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
91.5%
7.8 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 100.0% · Q3 100.0% · Q4 98.7% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.6%
0.1 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.7% · Q3 4.1% · Q4 4.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.8%
4.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 12.8% |
7.2%
5.6 pts worse
|
5.4%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 15.6% · Q3 12.7% · Q4 11.7% · 4Q avg 12.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.9% |
21.6%
3.7 pts better
|
19.6%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 16.9% · Q3 18.8% · Q4 19.4% · 4Q avg 17.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.3% |
15.0%
0.3 pts worse
|
16.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 15.7% · Q3 16.7% · Q4 15.1% · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 39.9% |
21.5%
18.4 pts worse
|
16.3%
23.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 39.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.2% |
16.8%
6.4 pts worse
|
14.9%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 38.6% · Q3 23.6% · Q4 16.4% · 4Q avg 23.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.9%
0.8 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.0% · Q3 0.9% · Q4 0.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
2.6%
0.4 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.1% · Q3 1.4% · Q4 2.7% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.4% |
21.2%
10.2 pts worse
|
19.8%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 34.8% · Q3 33.6% · Q4 37.9% · 4Q avg 31.4% |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
6.0%
1.7 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 4.1% · Q3 12.1% · Q4 7.7% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.1% |
79.9%
6.2 pts better
|
81.7%
4.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 76.1% · Q2 80.0% · Q3 93.4% · Q4 96.2% · 4Q avg 86.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.8% |
13.2%
8.6 pts worse
|
12.0%
9.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 20.2% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.1% |
78.1%
5 pts better
|
79.7%
3.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.9% |
22.9%
9 pts worse
|
23.9%
8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.9% · Observed 25.7% · Expected 19.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-30 · Fire 2023-08-30
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-03-31 · Fire 2022-03-31
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-01-17
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-01-17
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-01-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-01-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-02
D · Potential for more than minimal harm
2023-08-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-08-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-11
C · Minimal harm
2023-08-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-01-17
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-11-15
D · Potential for more than minimal harm
2025-01-17
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2025-02-06
D · Potential for more than minimal harm
2025-01-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-06
D · Potential for more than minimal harm
2025-01-17
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-01-20
J · Immediate jeopardy
2024-08-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-08-01
J · Immediate jeopardy
2024-08-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-24
D · Potential for more than minimal harm
2023-08-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-18
B · Minimal harm
2023-08-30
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-18
E · Potential for more than minimal harm
2022-03-31
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-04-20
D · Potential for more than minimal harm
2022-03-31
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-04-20
Penalties and ownership
What sits behind the stars
$7,823
2024-08-20
Fine
Fine · fine $7,823
Fine
$7,823
2024-08-20
Fine
Fine · fine $7,823
Fine
Ownership
Goins, Ted
Operational/Managerial Control · Individual
Lsa Management, Inc.
Operational/Managerial Control · Organization
Lutheran Services For The Aging, Inc.
Operational/Managerial Control · Organization
Maddry, Karen
Corporate Officer · Individual
Mccoy, Cynthia
Operational/Managerial Control · Individual
Nickerson, Kirby
Corporate Officer · Individual
Owens-Watterson, Dawn
Operational/Managerial Control · Individual
Smith, Kesha
Operational/Managerial Control · Individual
Smith, Kesha
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Cedar Hills Center for Nursing and Rehabilitation
Clemmons, NC
1-star overall rating with 2-star inspections with $70,269 in total fines with 12 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Bermuda Village Retirement Center
Bermuda Run, NC
3-star overall rating with 3-star inspections with $12,184 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Bermuda Commons Nursing and Rehabilitation Center
Advance, NC
1-star overall rating with 2-star inspections with $28,043 in total fines with 9 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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