What is Trinity Elms's Medicare star rating?

CMS rates Trinity Elms 2 out of 5 stars overall, with 3 for health inspections, 4 for staffing and 1 for quality measures (CMS data as of September 1, 2026).

How many deficiencies did Trinity Elms get at its last inspection?

5 health deficiencies at the standard inspection on March 19, 2026. The North Carolina average is 4.7.

Does Trinity Elms accept Medicaid?

It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.

Who owns Trinity Elms?

CMS lists 22 owners and managers, and links the home to Lutheran Services Carolinas. Legal business name: LUTHERAN HOME - FORSYTH COUNTY, INC..

Trinity Elms: Inspections, Staffing & Ratings

The record in brief

At its most recent standard inspection, on March 19, 2026, inspectors cited 5 health deficiencies (the North Carolina average is 4.7, the national average 9.2).

Of 14 health citations since August 2023, 2 were rated as actual harm or immediate jeopardy to residents (2 immediate jeopardy).

CMS lists 2 fines totaling $15,646 in the last three years; the largest was $7,823, and the latest is dated August 20, 2024.

Nurses and nurse aides worked 4.96 hours per resident per day, against 3.85 across North Carolina and 3.86 nationally. Registered nurses accounted for 0.70 of those hours.

50.5% of nursing staff left within the year CMS measured (North Carolina average 49.0%).

CMS links it to Lutheran Services Carolinas, an affiliated group of 9 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

208/23

208/24

401/25

104/25

503/26

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 14 health citations on file.

Severity

Isolated

Pattern

Widespread

Immediate jeopardy

Actual harm

Potential for more than minimal harm

10D

Potential for minimal harm

March 19, 2026Standard inspection, Complaint inspection · 5 citations

D

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

F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it

Inspectors wroteBased on record reviews, resident representative, staff, Medical Director and Nurse Practitioner (NP) interviews, when the facility notified the nurse practitioner (NP) and responsible party (RP) of knee pain on 1/30/26, the facility failed to inform the NP and RP the resident had fallen on 1/28/26. This affected medical diagnostics and treatment. The deficient practice affected 1 of 5 residents reviewed for accidents (Resident #33).
D

Ensure each resident receives an accurate assessment.

F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 31, 2026

Inspectors wroteBased on record review and staff interviews, the facility failed to code a Minimum Data Set (MDS) assessment in the areas of intravenous (IV) midline access (specialized vascular access device designed for patients requiring IV therapy for a moderate length of time), and IV antibiotic medication use (Resident #99) and insulin medication use (Resident #95) and behaviors (Resident #90) for 3 of 18 residents whose MDS assessments were reviewed.
D

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

F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 31, 2026

Inspectors wroteBased on record review, resident representative and staff interviews, the facility failed to develop a baseline care plan that addressed the resident's immediate needs related to fall prevention and pain management for 1 of 12 residents reviewed for baseline care plans (Resident #3).
D

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

F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 31, 2026

Inspectors wroteBased on record review and staff interviews, the facility failed to develop a comprehensive care plan in the areas of communication and behaviors for 1 of 18 residents whose care plans were reviewed (Resident #90). Findings Included:Resident # 90 was admitted to the facility on [DATE]. A review of Resident #90's behavior monitoring and interventions report revealed on 11/2/25 Resident #90 demonstrated behaviors of grabbing others, hitting others, physical aggression toward others, and agitation. On 11/3/25 Resident #90 demonstrated behaviors of hitting others, physical aggression toward others, agitation, anxiousness, and exit seeking behavior. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #90 had adequate hearing with the use of hearing aids, was usually understood, usually understood others and had no behaviors. [...]
D

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

F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it

Inspectors wroteBased on observations, record reviews, and resident representative, staff, Nurse Practitioner, and physician interviews, the facility failed to implement effective systems to effectively communicate and collaborate regarding the resident's care. The deficient practice affected 1 of 5 residents reviewed for accidents (Resident #33).

April 30, 2025Complaint inspection · 1 citation

D

Ensure that residents are free from significant medication errors.

F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 30, 2025

Inspectors wroteBased on interviews with the staff, Nurse Practitioner (NP), and Medical Doctor (MD), and Emergency Medical Services (EMS), hospital, and facility record reviews, the facility failed to correctly identify a resident when the medications ordered for one resident were inadvertently administered to another resident. This occurred for 1 of 3 resident (Resident #1) whose medications were reviewed.

January 17, 2025Standard inspection · 4 citations

F

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

F851 · Administration · No actual harm, potential for more than minimal harm, widespread · Past noncompliance: already fixed when inspectors found it

Inspectors wroteBased on record review and staff interviews, the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) related to Registered Nurse (RN) hours, licensed nursing coverage 24-hours per day. This was for 1 of 3 quarters reviewed for sufficient nurse staffing (Quarter 4 2024 July 1-September 30).
D

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.

F578 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 6, 2025

Inspectors wroteBased on staff interviews and record reviews the facility failed to maintain accurate advance directive information (code status) throughout both the electronic medical record and paper medical record for 1 of 1 resident reviewed for advance directive (Resident #48).
D

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

F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 6, 2025

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to post cautionary and safety signage outside of resident rooms that indicated the use of oxygen for 3 of 3 residents (Residents #57, #69, and #48) reviewed for respiratory care.
D

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.

F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 20, 2025

Inspectors wroteBased on record review, observations, and interviews with resident and staff, the facility failed to secure medications observed at bedside for 1 of 1 resident reviewed for medication storage (Resident #77).

August 20, 2024Complaint inspection · 2 citations

J

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

F580 · Resident Rights · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it

Inspectors wroteBased on record review, observations, interviews with staff, Dermatologist, and Medical Director, the facility staff failed to notify medical provider of a change in condition for a nonverbal resident with a diagnosis of diabetes when new skin wounds were observed on 7/22/24. The Medical Director was notified on 7/23/24 and Resident #1 was sent to the Emergency Department (ED) on 07/23/24 and was diagnosed with deep partial thickness burns to the anterior (front) and medial thighs bilaterally as well as the mons pubis (fatty tissue that covers the pubic bone). [...]
J

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

F689 · Quality of Life and Care · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it

Inspectors wroteBased on record review, observations, and interviews with staff, Hospital Case Manager, Plumbing Contractor, Dermatologist, and the Medical Director, the facility staff failed to supervise a severely cognitively impaired and nonverbal resident in the shower room. On 7/22/24 Nurse Aide (NA) #1 left Resident #1 unattended and naked on the shower bed with the water running on her body. When NA #1 returned to the shower spa, Resident #1 had a pool of water over her bilateral thighs and genital area. NA #1 took a washcloth to remove the puddle of water and noticed that Resident #1's top layer of skin on her bilateral upper thighs was peeling off. Resident #1 was sent to the Emergency Department (ED) 07/23/24 and was diagnosed with deep partial thickness burns to the anterior (front) and medial thighs bilaterally as well as the mons pubis (fatty tissue that covers the pubic bone). [...]

August 30, 2023Standard inspection · 2 citations

D

Ensure medication error rates are not 5 percent or greater.

F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 18, 2023

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to maintain a medication error rate of less than 5% as evidenced by a medication error rate of 7.69% (2 errors out of 26 opportunities) for Resident #60.
B

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

F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for minimal harm, pattern · deficient, provider has September 18, 2023

Inspectors wroteBased on record review and staff and local Department of Social Services (DSS) Adult Protective Services (APS) Supervisor interviews, the facility failed to report an allegation of resident abuse to Adult Protective Services within the required time frame for 1 of 1 resident abuse allegation reviewed (Resident #2).

Fire safety inspections

9 fire safety citations on file: 2 on March 19, 2026, 4 on January 17, 2025, 3 on August 30, 2023.

Every fire safety citation9 citations

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

K 321 · March 19, 2026 · Corrected (the home has a date of correction)
D
Provide properly protected cooking facilities.

K 324 · March 19, 2026 · Corrected (the home has a date of correction)
D
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.

K 222 · January 17, 2025 · Corrected (the home has a date of correction)
D
Install proper backup exit lighting.

K 281 · January 17, 2025 · Corrected (the home has a date of correction)
D
Inspect, test, and maintain automatic sprinkler systems.

K 353 · January 17, 2025 · Corrected (the home has a date of correction)
D
Have generator or other power source capable of supplying service within 10 seconds.

K 918 · January 17, 2025 · Corrected (the home has a date of correction)
D
Inspect, test, and maintain automatic sprinkler systems.

K 353 · August 30, 2023 · Corrected (the home has a date of correction)
D
Have generator or other power source capable of supplying service within 10 seconds.

K 918 · August 30, 2023 · Corrected (the home has a date of correction)
C
Install corridor and hallway doors that block smoke.

K 363 · August 30, 2023 · Corrected (the home has a date of correction)

Fines and payment denials

Date	Penalty	Amount or length
August 20, 2024	Fine	$7,823
August 20, 2024	Fine	$7,823

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

Measure	This home	North Carolina	United States
All nursing staff (RN, LPN and aides)	4.96	3.85	3.86
Registered nurses	0.70	0.62	0.69
All nursing staff on weekends	4.71	3.42	3.42
Nurse aides	3.46
Licensed practical nurses	0.80
Nursing staff turnover (share who left in a year)	50.5%	49.0%	45.8%
Registered nurse turnover	66.7%	45.6%	42.9%
Administrators who left	1

CMS expects 3.59 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.06 on weekdays and 4.71 on weekends, 7% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.86 in April to June 2025 to 4.96 in January to March 2026.

Quarter	All nursing staff	Registered nurses	Weekdays	Weekends	Contract staff share	Days with no RN hours	Residents a day
Jan to Mar 2026	4.96	0.70	5.06	4.71	0.0%	0 of 90	91
Oct to Dec 2025	4.28	0.53	4.38	4.03	0.0%	0 of 92	90
Jul to Sep 2025	4.28	0.63	4.39	4.00	0.0%	0 of 92	86
Apr to Jun 2025	3.86	0.38	3.97	3.58	0.0%	0 of 91	90
United States, Jan to Mar 2026	3.75	0.62	3.92	3.33	5.3%	0.5% of days
North Carolina, Jan to Mar 2026	3.65	0.53	3.82	3.25	8.0%	0.7% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

Measure	This home	North Carolina	US
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1	27.8	15.6	13.9
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1	0.5	0.7	0.8
Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1	2.1	2.3	1.6
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1	4.1	3.5	3.2
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1	0.3	1.4	1.6
Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1	44.3	18.3	14.1
Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1	7.4	5.5	4.6
Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1	16.7	14.0	15.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231	27.4	22.9	23.8
Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231	13.6	12.9	12.0
Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231	1.3	1.8	1.9
Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231	2.4	1.8	1.8

Owners and operators

Legal business name: LUTHERAN HOME - FORSYTH COUNTY, INC.. CMS links this home to Lutheran Services Carolinas, a group of 9 nursing homes averaging 4.2 stars overall.

Name	Role	Type	Since
Goins, Ted	Managing control - governing body	Individual	10/01/2004
Herman, Richard	Managing control - governing body	Individual	06/01/2022
Nelson, Douglas	Managing control - governing body	Individual	09/01/2022
Smith, Kesha	Corporate director	Individual	09/08/2003
Maddry, Karen	Corporate officer	Individual	01/01/2014
Nickerson, Kirby	Corporate officer	Individual	10/01/2012
Lsa Management, Inc.	Operational/managerial control	Organization	08/28/2008
Lutheran Services for the Aging, Inc.	Operational/managerial control	Organization	08/28/2008
Goins, Ted	Operational/managerial control	Individual	10/01/2004
McCoy, Cynthia	Operational/managerial control	Individual	06/26/2023
Owens-Watterson, Dawn	Operational/managerial control	Individual	05/03/2023
Smith, Kesha	Operational/managerial control	Individual	10/01/2012
Lutheran Services for the Aging, Inc.	Trustee of the SNF	Organization	08/28/2008
Goins, Ted	Trustee of the SNF	Individual	10/01/2004
Nelson, Douglas	Trustee of the SNF	Individual	09/01/2022
Lsa Elms Property, Inc	Adp of the SNF	Organization	03/16/2025
Lsa Management, Inc.	Adp of the SNF	Organization	03/16/2025
Goins, Ted	Adp of the SNF	Individual	10/01/2004
McCoy, Cynthia	Adp of the SNF	Individual	06/26/2003
Nickerson, Kirby	Adp of the SNF	Individual	10/01/2012
Owens-Watterson, Dawn	Adp of the SNF	Individual	05/03/2023
Smith, Kesha	Adp of the SNF	Individual	10/01/2012

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 3 problems in this area, most recently on March 19, 2026: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident."
When is the care plan meeting, and can family attend it?Inspectors cited 3 problems in this area, most recently on March 19, 2026: "Ensure each resident receives an accurate assessment."
How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 3 problems in this area, most recently on March 19, 2026: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 3 problems in this area, most recently on April 30, 2025: "Ensure that residents are free from significant medication errors."
How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.

Other nursing homes nearby

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Bermuda Village Retirement Center
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Bermuda Commons Nursing and Rehabilitation Center
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Homestead Hills
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Silas Creek Rehabilitation Center
Winston Salem, 6.9 mi · 4 of 5 stars · 3 citations
The Oaks
Winston-Salem, 7.3 mi · 2 of 5 stars · 24 citations
Willow Valley Center for Nursing and Rehabilitatio
Winston-Salem, 8.9 mi · 1 of 5 stars · 51 citations
Arbor Acres United Methodist Retirement Community
Winston Salem, 9.1 mi · 4 of 5 stars · 1 citation

North Carolina contacts for a concern about a nursing home

These are the official offices in North Carolina. NursingHomeClear cannot take or act on complaints.

Inspections and complaints: NC Division of Health Service Regulation, Nursing Home Licensure and Certification Section, the state agency that inspects nursing homes for CMS and takes complaints about care.
Resident advocate: North Carolina Long-Term Care Ombudsman Program. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
State inspection reports: NC DHSR Regulated Facilities search (Statements of Deficiencies), where North Carolina publishes its own records on licensed homes.

Common questions

What is Trinity Elms's Medicare star rating?: CMS rates Trinity Elms 2 out of 5 stars overall, with 3 for health inspections, 4 for staffing and 1 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Trinity Elms get at its last inspection?: 5 health deficiencies at the standard inspection on March 19, 2026. The North Carolina average is 4.7.
Has Trinity Elms been fined?: Yes. CMS lists 2 fines totaling $15,646 in the last three years.
Does Trinity Elms accept Medicaid?: It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Trinity Elms?: CMS lists 22 owners and managers, and links the home to Lutheran Services Carolinas. Legal business name: LUTHERAN HOME - FORSYTH COUNTY, INC..

Sources

Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
Owners: CMS Ownership. Penalties: CMS Penalties.
Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.