Trinity Grove
631 Junction Creek Drive, Wilmington, NC 28412 · CCN 345554
Abuse icon
Ratings
- Overall
- ★★★☆☆ 3
- Health inspection
- ★★☆☆☆ 2
- Quality measures
- ★★★☆☆ 3
- Staffing
- ★★★★★ 5
Facility
- Ownership type
- Non profit - Church related
- Certified beds
- 100
- Avg residents/day
- 93.1
- Phone
- 9104423000
Inspection history vs North Carolina & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | North Carolina avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-09-18 | 5 | 5.6 | 9.5 | -0.6 better |
| 2 | 2024-10-10 | 6 | 7.2 | 9.8 | -1.2 better |
| 3 | 2023-07-13 | 5 | 7.4 | 9.3 | -2.4 better |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Abuse, neglect, exploitation | 1 |
| Nursing and physician services | 1 |
| Resident rights | 2 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 4.36 | 45.8% |
| RN staffing (reported) | 0.96 | 41.7% |
| Total nurse staffing (adjusted) | 4.94 | — |
Fines & penalties
- Total fines
- $137,770
- Number of fines
- 4
- Number of penalties
- 4
- Payment denials
- 0
Chain
- Chain
- LUTHERAN SERVICES CAROLINAS
- Facilities in chain
- 9
- Chain avg overall
- 4.30 / 5
Inspection citations (16)2 immediate jeopardy2 actual harm
- EF0565Honor the resident's right to organize and participate in resident/family groups in the facility.2025-09-18 · Health · corrected 2025-10-08
Potential for more than minimal harm
- BF0585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.2025-09-18 · Health · corrected 2025-10-08
Potential for minimal harm
- GF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2025-09-18 · Health · corrected 2025-09-26
Actual harm
- CF0732Post nurse staffing information every day.2025-09-18 · Health · corrected 2025-10-08
Potential for minimal harm
- EF0880Provide and implement an infection prevention and control program.2025-09-18 · Health · corrected 2025-10-08
Potential for more than minimal harm
- GF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2024-10-10 · Health · corrected 2024-10-30
Actual harm
- DF0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.2024-10-10 · Health · corrected 2024-10-30
Potential for more than minimal harm
- DF0810Provide special eating equipment and utensils for residents who need them and appropriate assistance.2024-10-10 · Health · corrected 2024-10-30
Potential for more than minimal harm
- KF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2024-08-05 · Health · corrected 2023-11-21
Immediate jeopardy
- KF0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.2024-08-05 · Health · corrected 2023-11-21
Immediate jeopardy
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-08-05 · Health · corrected 2024-08-25
Potential for more than minimal harm
- DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2023-07-13 · Health · corrected 2023-08-15
Potential for more than minimal harm
- EF0761Ensure 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.2023-07-13 · Health · corrected 2023-08-15
Potential for more than minimal harm
- DF0811Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.2023-07-13 · Health · corrected 2023-08-15
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-07-13 · Health · corrected 2023-08-15
Potential for more than minimal harm
- EF0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.2023-05-09 · Health · corrected 2023-07-13
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| LUTHERAN SERVICES FOR THE AGING, INC. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2007-04-30 |
| LSA MANAGEMENT, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2007-04-30 |
| LUTHERAN HOME WILMINGTON PROPERTY, INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 1988-04-05 |
| LUTHERAN SERVICES FOR THE AGING, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2007-04-30 |
| GOINS, TED | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2004-11-04 |
| PARRISH, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-02-25 |
| SMITH, KESHA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2012-10-01 |
| SUTTON-SURAK, AUDREY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-02-25 |
| SMITH, KESHA | Individual | CORPORATE DIRECTOR | — | 2003-09-08 |
| MADDRY, KAREN | Individual | CORPORATE OFFICER | — | 2007-04-30 |
| NICKERSON, KIRBY | Individual | CORPORATE OFFICER | — | 2012-10-01 |
Other facilities in Wilmington
| Name | Overall | Beds |
|---|---|---|
| Cypress Pointe Rehabilitation Center | ★★★★★ | 90 |
| Bradley Creek Health Center | ★★★★★ | 30 |
| August Healthcare at Wilmington | ★★★☆☆ | 120 |
| Davis Health and Wellness Center at Cambridge Vill | ★★★☆☆ | 20 |
| Davis Health Care Center | ★★☆☆☆ | 115 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.