Trinity Elms

• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

30 of 419 North Carolina homes (7%) got a citation at the actual harm level in 2026.

• Citation F0684. Severity G: actual harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on May 28, 2026.

  CMS has cited this home for F0684 2 times since 2026.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on May 28, 2026.

  CMS has cited this home for F0689 2 times since 2024.

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CMS lists this as a standard inspection and a complaint inspection.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on February 4, 2026.

  CMS has cited this home for F0580 2 times since 2024.

• Citation F0641. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives an accurate assessment.

  CMS lists it as corrected on March 31, 2026.

• Citation F0655. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on March 31, 2026.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on March 31, 2026.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on February 4, 2026.

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CMS lists this as a standard inspection.

• Citation K0321. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on June 27, 2026.

• Citation K0324. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on June 27, 2026.

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• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Fine

  CMS changed the fine from August 20, 2024 from $15,646 to $7,823.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 1 of 5.

CMS lists this as a complaint inspection.

• Citation F0760. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on April 30, 2025.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 3 of 5.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 1 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 4.2 to 2.8 hours per resident per day.

CMS lists this as a standard inspection.

• Citation F0851. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on November 15, 2024.

• Citation F0578. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on February 6, 2025.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on February 6, 2025.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on January 20, 2025.

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CMS lists this as a standard inspection.

• Citation K0222. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on May 2, 2025.

• Citation K0281. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install proper backup exit lighting.

  CMS lists it as corrected on May 2, 2025.

• Citation K0353. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on May 2, 2025.

  CMS has cited this home for K0353 2 times since 2023.

• Citation K0918. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on May 2, 2025.

  CMS has cited this home for K0918 2 times since 2023.

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• Star rating

  The CMS overall star rating changed from 5 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 5 of 5 to 3 of 5.

• Name

  CMS lists a new legal business name for this home.

CMS lists this as a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

88 of 419 North Carolina homes (21%) got a citation at the immediate jeopardy level in 2024.

• Citation F0580. Severity J: immediate jeopardy, isolated.

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

  CMS lists it as corrected on August 1, 2024.

• Citation F0689. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on July 24, 2024.

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CMS fine of $7,823 on August 20, 2024.

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CMS fine of $7,823 on August 20, 2024.

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• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a standard inspection.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on September 18, 2023.

• Citation F0609. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on September 18, 2023.

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CMS lists this as a standard inspection.

• Citation K0353. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on November 11, 2023.

• Citation K0918. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on November 11, 2023.

• Citation K0363. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on November 11, 2023.

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