C
Trinity Elms
50/100 score
0.63 hrs RN staffing
5 deficiencies
Cedar Hills Center for Nursing and Rehabilitation
3905 Clemmons Road, Clemmons, NC 27012
F
Facility Assessment
19 federal violations at this facility remain unresolved. Inspectors recorded 2 citations at the actual-harm level or worse in the last three survey cycles. This facility staffs below 0.55 RN hours per resident day — the level the 2024 federal rule, repealed in February 2026, would have required.
Below the repealed 0.55 hr RN benchmark — review inspection history before visiting.
Quality Breakdown
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RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
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0.20 — Below the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
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Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
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Total
49
Outstanding
19
Actual harm or worse (G–L)
2
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CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
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Quality: ★☆☆☆☆ (1/5)
Staffing: ★☆☆☆☆ (1/5)
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NursingHomeGrade Score
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0/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
1 immediate jeopardy, 1 actual harm issues found among 49 total deficiencies. 30 corrected. — 19 still outstanding
Most recent inspection (February 13, 2026)
D
Potential harm — isolated
F0770
Status: Outstanding — No Plan
Provide timely, quality laboratory services/tests to meet the needs of residents.
Administration Deficiencies — Deficient, Provider has no plan of correction
F
Potential harm — widespread
F0881
Status: Outstanding — No Plan
Implement a program that monitors antibiotic use.
Infection Control Deficiencies — Deficient, Provider has no plan of correction
E
Potential harm — pattern
F0883
Status: Outstanding — No Plan
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies — Deficient, Provider has no plan of correction
D
Potential harm — isolated
F0880
Status: Outstanding — No Plan
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has no plan of correction
F
Potential harm — widespread
F0812
Status: Outstanding — No Plan
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has no plan of correction
F
Potential harm — widespread
F0814
Status: Outstanding — No Plan
Dispose of garbage and refuse properly.
Nutrition and Dietary Deficiencies — Deficient, Provider has no plan of correction
D
Potential harm — isolated
F0761
Status: Outstanding — No Plan
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.
Pharmacy Service Deficiencies — Deficient, Provider has no plan of correction
D
Potential harm — isolated
F0690
Status: Outstanding — No Plan
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction
D
Potential harm — isolated
F0677
Status: Outstanding — No Plan
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction
D
Potential harm — isolated
F0686
Status: Outstanding — No Plan
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction
E
Potential harm — pattern
F0655
Status: Outstanding — No Plan
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has no plan of correction
D
Potential harm — isolated
F0656
Status: Outstanding — No Plan
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has no plan of correction
C
No harm — widespread
F0577
Status: Outstanding — No Plan
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Resident Rights Deficiencies — Deficient, Provider has no plan of correction
D
Potential harm — isolated
F0578
Status: Outstanding — No Plan
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.
Resident Rights Deficiencies — Deficient, Provider has no plan of correction
D
Potential harm — isolated
F0582
Status: Outstanding — No Plan
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Rights Deficiencies — Deficient, Provider has no plan of correction
D
Potential harm — isolated
F0550
Status: Outstanding — No Plan
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies — Deficient, Provider has no plan of correction
Inspection cycle 2 (November 8, 2024)
C
No harm — widespread
F0575
Status: Outstanding — Plan Filed
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Resident Rights Deficiencies — Deficient, Provider has plan of correction, corrected December 10, 2024
D
Potential harm — isolated
F0835
Status: Corrected
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Administration Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
D
Potential harm — isolated
F0914
Status: Corrected
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Environmental Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
D
Potential harm — isolated
F0609
Status: Corrected
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 11, 2024
D
Potential harm — isolated
F0755
Status: Corrected
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 11, 2024
E
Potential harm — pattern
F0760
Status: Corrected
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 11, 2024
D
Potential harm — isolated
F0690
Status: Corrected
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 11, 2024
D
Potential harm — isolated
F0697
Status: Corrected
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 11, 2024
D
Potential harm — isolated
F0688
Status: Corrected
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
G
Actual harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
D
Potential harm — isolated
F0698
Status: Corrected
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
D
Potential harm — isolated
F0636
Status: Corrected
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
E
Potential harm — pattern
F0658
Status: Corrected
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
D
Potential harm — isolated
F0580
Status: Corrected
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 11, 2024
D
Potential harm — isolated
F0583
Status: Corrected
Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
E
Potential harm — pattern
F0565
Status: Corrected
Honor the resident's right to organize and participate in resident/family groups in the facility.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
D
Potential harm — isolated
F0622
Status: Corrected
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
D
Potential harm — isolated
F0624
Status: Corrected
Prepare residents for a safe transfer or discharge from the nursing home.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 10, 2024
Inspection cycle 3 (November 17, 2023)
B
No harm — pattern
F0623
Status: Outstanding — Plan Filed
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies — Deficient, Provider has plan of correction, corrected May 11, 2023
B
No harm — pattern
F0584
Status: Outstanding — Plan Filed
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies — Deficient, Provider has plan of correction, corrected December 15, 2023
E
Potential harm — pattern
F0867
Status: Corrected
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2023
E
Potential harm — pattern
F0727
Status: Corrected
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2023
E
Potential harm — pattern
F0804
Status: Corrected
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2023
D
Potential harm — isolated
F0759
Status: Corrected
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2023
E
Potential harm — pattern
F0761
Status: Corrected
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2023
J
Immediate jeopardy — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 11, 2023
D
Potential harm — isolated
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2023
E
Potential harm — pattern
F0698
Status: Corrected
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2023
E
Potential harm — pattern
F0677
Status: Corrected
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2023
D
Potential harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2023
D
Potential harm — isolated
F0641
Status: Corrected
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2023
D
Potential harm — isolated
F0656
Status: Corrected
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2023
E
Potential harm — pattern
F0558
Status: Corrected
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2023
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