Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Trinity Elms during CMS and state inspections, most recent first.
Multiple MDS assessments were inaccurately coded when one resident admitted with pneumonia and meningitis, who had documented IV access, midline catheter use, and IV ceftriaxone therapy, was not coded for IV access or IV antibiotics on the MDS. Another resident with Type 2 DM receiving subcutaneous Tirzepatide was incorrectly coded as having received an insulin injection after the MDS nurse mistakenly assumed Tirzepatide was insulin, despite no insulin being documented on the MAR. A third resident with anxiety disorder had multiple documented behaviors such as yelling, hitting, aggression, agitation, exit seeking, and refusing care during the MDS look-back period, but was coded as having no behaviors because the social work staff relied only on direct observation and did not review the electronic medical record for documented behaviors.
A resident with chronic pain, mild dementia, severe neurocognitive disorder, debility, and impaired mobility was admitted with documented high fall risk and physician orders for PRN acetaminophen ER and a daily lidocaine patch for pain. Within 48 hours, the MDS nurse completed a baseline care plan that addressed transfer status, therapy, and dietary needs but omitted goals and interventions for pain management and did not include fall prevention measures, despite the fall risk evaluation indicating that prevention protocols should be initiated and documented. The resident’s representative reported ongoing pain and perceived high fall risk and wanted staff to be aware of these needs, while the DON and Administrator later acknowledged that the baseline care plan should have contained this essential information.
A resident with documented episodes of grabbing, hitting, physical aggression, agitation, anxiousness, and exit-seeking did not have communication or behavior needs addressed in the comprehensive care plan. Although the admission MDS showed adequate hearing with hearing aids and no behaviors at that time, the CAA identified communication as a triggered area to be care planned. The Social Work Assistant completed the CAA based only on the resident’s behavior during the assessment, did not review the EMR behavior monitoring reports, and was unaware of the need to do so. As a result, no communication or behavior interventions were added to the care plan, a lapse later acknowledged by both the Social Work Assistant and the DON.
A resident with dementia, failure to thrive, a fall history, and HTN was found on the floor by an RN, who assessed for pain and injury but did not notify the NP, responsible party, DON, or Medical Director of the fall and entered the event in the EMR as an injury rather than a fall. Two days later, the resident reported new right knee pain and swelling; the NP and family were informed only of the pain, not the prior fall, and an x-ray was ordered. Over the following days, the resident continued to report pain, received multiple analgesics, and underwent imaging, culminating in a CT that showed multiple right hip and pelvic fractures. The NP, Medical Director, and resident representative all reported they were not made aware of the fall until after the CT results and subsequent internal review, and hospital records later documented admission for a displaced right acetabular fracture and severe pain with functional decline after a fall at the facility.
A resident with dementia, gait abnormalities, and a history of falls was found on the floor in front of a wheelchair and assessed by an RN, who documented no pain or injury and returned the resident to a wheelchair. The RN entered the event in the EMR as an injury rather than a fall, did not complete required fall risk and post‑fall evaluations, and did not report the fall in shift report, so management and the primary provider were not promptly notified and automated fall protocols were not triggered. Over subsequent days, the resident repeatedly complained of right leg pain with documented pain scores and received PRN analgesics while outside imaging orders were delayed and not clearly communicated to the NP. When the NP later assessed the resident for persistent discomfort and limited ROM, a hip/pelvis x‑ray and then a CT scan were ordered, ultimately revealing multiple right hip and pelvic fractures. Interviews and record review showed that the fall was not disclosed to the NP or family until after the CT results and internal investigation, demonstrating a breakdown in communication, documentation, and interdisciplinary coordination around the resident’s fall and subsequent pain complaints.
A medication aide mistakenly administered a set of medications intended for another resident to a resident with severe cognitive impairment after misidentifying her during a medication pass. The error involved multiple medications, including antihypertensives and psychotropics, and was discovered after the aide realized the mistake and reported it. The resident was monitored and found to be stable, with no acute distress or adverse reactions noted.
The facility failed to submit accurate PBJ data to CMS, missing RN hours and 24-hour licensed nursing coverage for several days in a quarter. Despite having the required staffing, errors in reporting led to the deficiency, which was later corrected.
A facility failed to maintain consistent advance directive information for a resident, resulting in a discrepancy between the EMR and paper medical record. The resident's EMR indicated a full code status, while the paper record showed a signed DNR form. Staff interviews confirmed the inconsistency, with the DON and Administrator expecting records to match.
The facility failed to post required cautionary and safety signage for three residents receiving oxygen therapy. Despite physician orders for continuous oxygen administration, observations revealed that these residents were receiving oxygen without any signage indicating its use. Interviews with the DON and Administrator confirmed that signage was expected but not implemented.
A resident, not approved to self-administer medications, was found with medications left unsecured on their overbed table. The nurse mistakenly believed the resident could self-administer, leading to a breach in medication storage protocols. The DON confirmed this was against facility policy.
A nonverbal resident with diabetes in an LTC facility developed skin wounds during a shower, which were not promptly reported to the medical provider. The resident's condition worsened overnight, leading to a diagnosis of deep partial thickness burns. The delay in notification increased the risk of infection, especially given the resident's diabetes.
A resident with severe cognitive impairment was left unattended in a shower by a nurse aide, resulting in deep partial thickness burns to her thighs and mons pubis. The resident, who required total assistance for care, was found with peeling skin after being left with running water. The incident highlighted a lack of supervision and failure to follow proper procedures, leading to the resident's hospitalization and treatment.
Inaccurate MDS Coding for IV Therapy, Insulin Use, and Behaviors
Penalty
Summary
The deficiency involves inaccurate coding of Minimum Data Set (MDS) assessments for multiple residents, resulting in failure to capture IV therapy, IV antibiotic use, insulin use, and behavioral symptoms. One resident was admitted with pneumonia and meningitis requiring IV access and IV antibiotic medications. Documentation showed the resident arrived with IV access in the right antecubital fossa, had physician orders for IV ceftriaxone every 12 hours, and received IV antibiotics and saline flushes over several days, with notes indicating use of a midline catheter. However, the discharge return not anticipated MDS assessment did not indicate the presence of a midline IV access or that IV antibiotics were received upon admission, during the stay, or at discharge. The MDS Nurse later acknowledged that IV access and IV antibiotic use were not marked and that this was an error. Another resident with Type 2 diabetes mellitus with hyperglycemia had a physician order for Tirzepatide to be administered subcutaneously once weekly, and the Medication Administration Record confirmed that this medication was given as ordered. There was no indication on the MAR that the resident received any insulin injections. Despite this, the admission MDS assessment coded that the resident had received one insulin injection. The MDS Nurse who completed the assessment stated she coded one insulin injection because she believed Tirzepatide was considered insulin and later realized this was incorrect, confirming that the MDS had been inaccurately coded. A third resident admitted with an anxiety disorder exhibited multiple documented behaviors during the MDS assessment look-back period, including grabbing others, hitting, physical aggression, agitation, anxiousness, exit seeking, yelling, throwing medication, refusing care, restlessness, and wandering. These behaviors were recorded on behavior monitoring reports and in progress notes by nursing staff and the Administrator. Despite this documentation, the admission MDS with an Assessment Reference Date within this period coded the resident as having no behaviors, although it did indicate severe cognitive impairment and receipt of antianxiety medication. The Social Work Assistant responsible for coding behaviors on the MDS stated she did not observe these behaviors during the assessment period, was not aware she needed to review the electronic medical record for documented behaviors, and was unaware that such behaviors had been documented, leading to the omission of behaviors on the MDS.
Failure to Include Fall Risk and Pain Management in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan that addressed a newly admitted resident’s immediate needs related to fall prevention and pain management. Record review showed the resident had diagnoses of chronic neck pain, chronic pain syndrome, mild dementia, severe major neurocognitive disorder, debility, and impaired mobility. Hospital documentation indicated a recent cognitive and functional decline, increased confusion, difficulty ambulating with a walker, generalized weakness, and reduced mobility. On admission, the facility’s fall risk evaluation identified the resident as being at high risk for potential falls, with instructions that fall prevention protocols should be initiated immediately and documented on the care plan. Physician orders at admission included PRN acetaminophen extended release for pain and a daily lidocaine 4% patch for lower back pain. Despite this information, the baseline care plan completed within 48 hours of admission did not include goals or interventions for the resident’s chronic pain syndrome and did not address the resident’s immediate needs related to fall risk prevention. The MDS nurse who completed the baseline care plan stated it included transfer status, therapy, and dietary information and believed it met minimum requirements for basic safety. The resident’s representative reported that the resident had a history of chronic pain requiring medication for comfort, that his pain continued after admission, and that she believed he was at high risk for falls due to his physical and mental condition, and wanted staff to be aware of these issues. The DON and Administrator both stated that a baseline care plan should include the minimum healthcare information necessary to meet a resident’s needs, and the DON acknowledged that the resident’s high fall risk and pain should have been included, but they were not.
Failure to Develop Communication and Behavior Care Plans for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive care plan addressing communication and behavioral needs for one resident. The resident was admitted on a specified date, and behavior monitoring and intervention reports documented multiple episodes of problematic behaviors, including grabbing others, hitting others, physical aggression toward others, agitation, anxiousness, and exit-seeking on consecutive days. The admission MDS assessment indicated the resident had adequate hearing with hearing aids, was usually understood and usually understood others, and showed no behaviors at that time. The Care Area Assessment (CAA) summary, completed shortly after admission by the previous Social Work Assistant, showed that communication was a triggered care area and stated that communication would be addressed in the care plan. Despite these findings, review of the resident’s care plan, dated shortly after admission with a later revision date, revealed no care plan or interventions in the areas of communication or behaviors. In a telephone interview, the previous Social Work Assistant confirmed she completed the communication CAA summary and acknowledged the resident should have had a communication care plan, but she did not know why one had not been developed. She stated she based her CAA answers solely on the resident’s behavior during the assessment, when no behaviors were observed, and she did not review the electronic medical record’s behavioral monitoring and intervention report because she did not know she needed to do so. The DON also stated that the resident should have had communication and behavior care plans and was unsure why they had not been completed.
Failure to Notify Provider and Representative of Resident Fall and Subsequent Pain
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify the nurse practitioner (NP) and the resident representative of a resident’s fall and to clearly communicate the occurrence of that fall when later reporting new pain symptoms. The resident, who had non-Alzheimer’s dementia, adult failure to thrive, a history of falling, and hypertension, was found on the floor in front of her wheelchair on 1/28/26. Nurse #7, who had just started her shift, assessed the resident for pain and injury, checked range of motion, and documented that the resident denied pain and had no apparent injury. Nurse #7 did not notify the provider, the family, or the DON of the fall on that date and believed the fall was witnessed by the Scheduler. The DON later stated that the incident was entered in the electronic medical record as an “injury” rather than a “fall,” which prevented the system from triggering the facility’s fall risk and post-fall evaluations. On 1/30/26, the resident began complaining of right knee pain, rated 4/10, and was given acetaminophen. A health status note by Nurse #11 documented that the NP was notified of the resident’s knee pain and slight swelling, and an x-ray was ordered. The resident’s family, who visited that day, was also notified of the complaint of right knee pain, but neither the NP nor the family was informed that the resident had been found on the floor two days earlier. The NP later confirmed she was never officially notified of the 1/28/26 fall and ordered the x-ray based solely on the reported pain. The NP stated she typically would be called when a resident fell and that she did not learn of the fall until 2/11/26, after CT results were available and the facility began an internal investigation. In the days following the onset of pain, the resident continued to report pain of varying intensity, including right lower extremity thigh/knee pain, and received acetaminophen, tramadol, and hydrocodone-acetaminophen. An x-ray could not be completed on one date due to snow, and the family initially requested waiting to send the resident out, later agreeing to further evaluation when the pain migrated to the hip. An x-ray of the knee was eventually done and was reported as fine, with a recommendation for CT if pain persisted. A CT scan performed on 2/9/26 revealed multiple serious fractures of the right hip and pelvis and flattening of the superior lateral right femoral head. The resident representative stated she was not notified of the 1/28/26 fall and only became aware of it in February when discussing CT results with the NP. The Medical Director also reported not being informed of the fall until 2/11/26, learning of it through record review. Hospital records documented that the resident was admitted with a displaced transverse-posterior fracture of the right acetabulum and severe pain with functional decline after experiencing a fall at the nursing facility.
Failure to Document and Communicate Fall Led to Delayed Identification of Fractures and Ongoing Pain
Penalty
Summary
The deficiency involves the facility’s failure to implement effective systems for communication, collaboration, assessment, and documentation following a resident fall, resulting in delayed recognition and response to injury and ongoing pain. Resident #33, who had hypertension, non‑Alzheimer’s dementia, adult failure to thrive, generalized muscle weakness, gait and mobility abnormalities, a history of falls, and used a wheelchair, was care planned as being at moderate risk for falls with interventions such as a wing‑tip mattress and prompt response to assistance needs. On the afternoon of 1/28/26, the Scheduler observed the resident already on the floor, sitting on her buttocks in front of her wheelchair, and summoned a nurse and a medication aide. Nurse #7 assessed the resident, checked range of motion, obtained vital signs, and asked about pain; the resident denied pain, and no apparent injury was noted. The resident was assisted back into her wheelchair and taken to the nurse’s station for brief observation before returning to routine activities. Despite this event, Nurse #7 did not document the occurrence as a fall in the electronic medical record, instead entering it as an “injury” incident type, which did not trigger the facility’s fall‑related User‑Defined Assessments (Fall Risk and Post Fall Evaluations). There was no contemporaneous Post Fall Evaluation or Fall Risk Evaluation completed for the 1/28/26 event, and the fall was not included in the shift report. As a result, management, the primary provider, and the resident’s representative were not promptly informed of the fall. The DON later confirmed that the misclassification of the event in the EMR prevented automatic initiation of the fall assessments and associated management investigation. The NP stated she was never officially notified of the 1/28/26 fall at the time it occurred and that she typically expected a call from the facility when a resident fell. Following the 1/28/26 incident, the resident began complaining of right knee pain on 1/30/26, with documented pain scores and administration of acetaminophen and later tramadol and hydrocodone‑acetaminophen. Nursing staff notified the NP of knee pain and slight swelling, and a right knee x‑ray was ordered on 1/30/26; due to weather and scheduling issues with the outside imaging company, this x‑ray was delayed, and the NP was not made aware of the delay until a later facility visit. The 1/30/26 knee x‑ray, when eventually completed, showed no acute fracture. On 2/4/26, during an on‑site visit, the NP observed the resident to be uncomfortable, irritable, frequently repositioning, and apparently not bearing weight on the right side, with complaints of pain and limited ROM of the right leg; staff at that time reported “no known injury.” Based on this assessment, the NP ordered a right hip/pelvis x‑ray, which showed arthritic changes and osteopenia but recommended CT if clinical suspicion for fracture persisted. A CT scan performed on 2/9/26 revealed multiple serious fractures of the right hip and pelvis. Throughout this period, the resident had repeated documented pain scores, and the NP and Medical Director both reported that they and the family only became aware of the 1/28/26 fall after the CT results and subsequent internal investigation, underscoring that the initial fall event and subsequent pain complaints were not effectively communicated or linked by staff to a potential injury from the fall. A late entry Post Fall Note was created by the ADON on 2/12/26, backdated to 1/28/26, describing the resident on the floor in front of her wheelchair, the assessment with no apparent injury, and the use of the PAINAD scale, but this documentation occurred only after the CT scan identified fractures and after the facility began investigating the cause of the injuries. Interviews with the DON, Unit Manager, NP, Medical Director, and other staff confirmed that the fall was initially treated as a non‑injurious event, that required fall assessments and notifications were not completed at the time, and that there were gaps in communication about both the fall and the delays in obtaining imaging. The surveyors concluded that the facility failed to implement effective systems to ensure timely communication and collaboration regarding the resident’s care, including accurate classification and documentation of the fall, prompt notification of the provider and resident representative, and timely follow‑up on persistent pain and imaging orders. Hospital records later documented that the resident was admitted after a fall at the nursing facility with a serious right hip socket fracture and severe pain and difficulty moving. The Medical Director’s first post‑fall visit with the resident occurred on 2/11/26, well after the 1/28/26 fall, and she reported that at that time the resident did not appear to be in pain but was agitated. The NP stated that had she known about the fall when it occurred, she might have ordered different or more extensive imaging earlier and would have considered sending the resident to the emergency department if injury was suspected. The deficiency centers on the facility’s failure to recognize, document, and communicate the 1/28/26 fall as such, failure to complete required fall‑related assessments, and failure to effectively coordinate provider notification and diagnostic follow‑up in the context of the resident’s ongoing pain and functional changes. Overall, the events show that the resident’s fall was not properly reported or documented in real time, the EMR entry did not trigger the facility’s fall management protocols, and key clinical staff and the resident’s representative were not promptly informed of the fall. Subsequent pain complaints, behavioral changes, and functional limitations were managed without clear linkage to a known fall event, and imaging orders were delayed or not effectively followed up, contributing to a prolonged period before the resident’s fractures were identified. These actions and inactions, as documented by staff interviews, record reviews, and practitioner statements, constitute the basis of the cited deficiency for failure to provide treatment and care in accordance with orders, resident preferences, and goals through effective communication and collaboration.
Medication Error Due to Resident Misidentification
Penalty
Summary
A medication error occurred when a medication aide administered a set of medications intended for one resident to another resident with severe cognitive impairment. The aide had previously given the correct morning medications to the resident, but later, due to changes in the resident's appearance and a case of mistaken identity, she addressed the resident by another's name and administered the wrong medications. The aide realized the error about an hour later and reported it to the nurse on duty. The resident who received the incorrect medications had a complex medical history, including hypertensive heart disease with heart failure, atrial fibrillation, and dementia with behaviors. The medications erroneously administered included multiple antihypertensives, an antipsychotic, an antidepressant, an antibiotic, and other medications not prescribed for her. At the time of the error, the resident was alert, at her baseline, and did not exhibit any acute distress or adverse reactions, though her blood pressure was monitored and found to be slightly low but stable. The incident was confirmed through interviews with the medication aide, the nurse, the nurse practitioner, and the medical director, as well as a review of the resident's medical records, EMS, and hospital documentation. The facility's DON stated that staff are expected to follow the six rights of medication administration, which were not adhered to in this case, resulting in the administration of another resident's medications to the wrong individual.
Inaccurate PBJ Reporting of RN Hours and Nursing Coverage
Penalty
Summary
The facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) regarding Registered Nurse (RN) hours and licensed nursing coverage for 24 hours per day. This issue was identified for one of the three quarters reviewed, specifically Quarter 4 of 2024. The PBJ report indicated that there were no RN hours recorded for several days in September 2024, and the facility also failed to have licensed nursing coverage for 24 hours per day on multiple days during the same month. Upon review of the Posted Daily Nursing Staffing Forms, Daily Staffing Sheet, and nursing staff time detail reports, it was found that there were indeed RN hours and 24-hour licensed nursing coverage for the days in question. An interview with the Human Resources Payroll Manager revealed that the PBJ data file submitted for September 2024 was initially rejected due to errors, which were later corrected and resubmitted successfully. The Administrator confirmed that the facility had the required RN hours and licensed nursing staff, attributing the issue to a reporting error.
Inconsistent Advance Directive Information for Resident
Penalty
Summary
The facility failed to maintain consistent and accurate advance directive information for a resident, leading to a discrepancy between the electronic medical record (EMR) and the paper medical record. The resident, who was moderately cognitively impaired, had a physician's order in the EMR indicating a full code status dated 12/12/24, while the paper medical record at the nurse's station contained a signed Do Not Resuscitate (DNR) form dated 12/16/24. This inconsistency was identified during staff interviews and record reviews. Nurse #1 confirmed the discrepancy and stated that in an emergency, she would first check the paper medical record. If there was a discrepancy, she would consult with the Director of Nursing (DON). The DON and the Administrator both expressed that their expectation was for the EMR and paper medical records to match. However, the inconsistency remained, indicating a failure in the facility's process to ensure that critical information regarding the resident's code status was accurately reflected across all records.
Failure to Post Oxygen Safety Signage
Penalty
Summary
The facility failed to post cautionary and safety signage outside the rooms of three residents who were receiving oxygen therapy. Resident #57, admitted with pneumonia due to hemophilus influenzae, had a physician's order for continuous oxygen administration via nasal cannula at 1 Liter/minute. Observations on two separate occasions revealed that Resident #57 was receiving oxygen without any cautionary signage posted at the entrance to her room. Similarly, Resident #69, admitted with acute respiratory failure with hypoxia, had orders for oxygen titration up to 2 Liters/minute. Observations showed that Resident #69 was receiving oxygen at varying levels without the required safety signage outside his room. Resident #48, who was admitted with pneumonia, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease, also had a physician's order for continuous oxygen at 2 Liters/minute. Observations confirmed that Resident #48 was receiving oxygen without any safety signage posted at the entrance to her room. Interviews with the Director of Nursing and the Administrator revealed that it was their expectation that the required oxygen signage be posted for residents receiving oxygen, indicating a lapse in adherence to safety protocols.
Failure to Secure Medications for Resident
Penalty
Summary
The facility failed to secure medications for a resident who was not approved to self-administer medications. Resident #77, who was admitted with diagnoses including cerebral infarction, hypertension, and anxiety, was assessed on 9/13/24 and found to require assistance with oral medications. Despite this assessment, medications were observed on the resident's overbed table during a survey on 1/13/25. The resident confirmed that it was common practice for the nurse to leave medications on the table for later consumption. Nurse #1, who left the medications on the table, mistakenly believed that the resident was approved to self-administer. The medications included Gabapentin, Labetalol, Clopidogrel, Zetia, Lasix, Isosorbide, Cozaar, a multivitamin, and Zoloft. The Director of Nursing confirmed that the medications should not have been left at the bedside, indicating a lapse in following the facility's medication storage protocols.
Failure to Notify Medical Provider of Resident's Condition Change
Penalty
Summary
The facility staff failed to notify the medical provider of a change in condition for a nonverbal resident with diabetes when new skin wounds were observed. The resident, who was severely cognitively impaired and nonverbal, was found to have skin tears on both thighs during a scheduled shower. The nurse on duty assessed the resident and noted redness and skin peeling on the thighs and mons pubis. Despite the visible injuries, the nurse did not notify the medical provider due to time constraints and instead passed the information to the oncoming nurse. The subsequent nurse also failed to notify the medical provider, assuming the previous nurse had done so. The resident's condition worsened overnight, with increased redness and irritation observed by the morning shift nurse. It was only after the wound nurse's assessment that the Assistant Director of Nursing was notified, who then contacted the medical provider. The resident was sent to the emergency department and diagnosed with deep partial thickness burns. Interviews with the medical director and dermatologist confirmed that the facility should have contacted the medical provider immediately upon noticing the change in the resident's condition. The dermatologist's assessment indicated that the injuries were consistent with thermal burns, possibly from hot water or a hot washcloth. The delay in notifying the medical provider increased the risk of infection, especially given the resident's diabetes and the severity of the burns.
Resident Left Unattended in Shower Results in Burns
Penalty
Summary
The facility staff failed to adequately supervise a severely cognitively impaired and nonverbal resident during a shower, leading to significant injuries. On the specified date, a nurse aide left the resident unattended and naked on a shower bed with the water running. Upon returning, the aide found the resident with a pool of water over her thighs and genital area, and the top layer of her skin was peeling off. The resident was subsequently diagnosed with deep partial thickness burns to her thighs and mons pubis, requiring hospitalization and treatment. The resident involved had a complex medical history, including lumbar degenerative disc disease, fibromyalgia, diabetes, heart failure, chronic kidney disease, and vascular dementia. She was severely cognitively impaired, nonverbal, and required total assistance for all care. Despite these needs, the care plan did not address behaviors such as scratching, which was noted during the incident. The nurse aide's decision to leave the resident unattended in the shower room without supervision or a call for assistance contributed to the incident. Interviews and documentation revealed inconsistencies in the reporting and assessment of the resident's condition before and after the incident. The nurse aide initially reported no skin issues, but later noted skin alterations after the shower. The facility's response included multiple interviews and assessments, but the initial lack of supervision and failure to follow proper procedures in the shower room were critical factors leading to the resident's injuries.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 170 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Clemmons
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedar Hills Center For Nursing And Rehabilitation | 0.9 mi | ★★★★★ | 38 | 0 |
| Bermuda Village Retirement Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Bermuda Commons Nursing And Rehabilitation Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Homestead Hills | 6.1 mi | ★★★★★ | 0 | 0 |
| Silas Creek Rehabilitation Center | 6.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Trinity Elms.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.