Trinity Grove
631 Junction Creek Drive, Wilmington, NC 28412 · New Hanover County · 100 certified beds · avg 95 residents/day · certified since Jun 29, 2011
Abuse citation flag (CMS)
Part of chain: LUTHERAN SERVICES CAROLINAS (9 facilities, chain avg rating 4.2★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Aug 5, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Nov 21, 2023 (Past Non-Compliance)
▲ Immediate jeopardy, repeated · Aug 5, 2024 · F-0607 · triggered by a complaint
The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Why it matters: Without working prevention policies, mistreatment is more likely to happen and less likely to be caught.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Nov 21, 2023 (Past Non-Compliance)
▲ Actual harm, one-off · Sep 18, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 26, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 10, 2024 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 30, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (15)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Sep 18, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Sep 18, 2025 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Sep 18, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 18, 2025 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Sep 18, 2025 | B · Minimal risk, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Oct 10, 2024 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Oct 10, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Oct 10, 2024 | D · Potential for harm, one-off | The facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals. |
| Aug 5, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Aug 5, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Aug 5, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jul 13, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 13, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 13, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jul 13, 2023 | D · Potential for harm, one-off | The facility did not properly run its feeding assistant program — assessing which residents are appropriate for it, following each resident's care plan, and making sure feeding assistants are trained and supervised. Feeding assistants are trained helpers who assist residents at mealtimes. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 4 | 0 | E |
| 2024 | 6 | 3 | K ▲ |
| 2025 | 5 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
4 fines totaling $102,910.
| Date | Type | Amount / length |
|---|---|---|
| Sep 18, 2025 | Fine | $64,740 |
| Oct 10, 2024 | Fine | $21,085 |
| Aug 5, 2024 | Fine | $8,542 |
| Aug 5, 2024 | Fine | $8,543 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | North Carolina avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.83 | 4.01 | 3.95 | top 14% in North Carolina; top 16% in the U.S. |
| Registered Nurse hours | 0.92 | 0.64 | 0.69 | top 15% in North Carolina; top 20% in the U.S. |
| Weekend total nurse staffing | 4.26 | 3.56 | 3.50 | top 14% in North Carolina; top 16% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.42 | 0.41 | 0.48 | top 31% in North Carolina; top 44% in the U.S. |
| Total nursing staff turnover (%) | 45.5 | 49.0 | 45.8 | top 42% in North Carolina; bottom 49% in the U.S. |
| RN turnover (%) | 30.8 | 45.7 | 42.9 | top 25% in North Carolina; top 30% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.37, RN 0.83, weekend 3.85. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 2/5 · short-stay residents: 4/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Goins, Ted | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/04/2004 |
| Goins, Ted | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/04/2004 |
| Goins, Ted | Individual | Trustee of the SNF | NOT APPLICABLE | 11/04/2004 |
| Goins, Ted | Individual | ADP of the SNF | NOT APPLICABLE | 11/04/2004 |
| Herman, Richard | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/01/2021 |
| Herman, Richard | Individual | Trustee of the SNF | NOT APPLICABLE | 06/01/2021 |
| Lsa Management, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/30/2007 |
| Lsa Management, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 03/16/2025 |
| Lutheran Home Wilmington Property, INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/05/1988 |
| Lutheran Home Wilmington Property, INC | Organization | ADP of the SNF | NOT APPLICABLE | 04/14/2025 |
| Lutheran Services for the Aging, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/30/2007 |
| Lutheran Services for the Aging, INC. | Organization | Trustee of the SNF | NOT APPLICABLE | 04/30/2007 |
| Lutheran Services for the Aging, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 04/25/2025 |
| Maddry, Karen | Individual | Corporate Officer | NOT APPLICABLE | 04/30/2007 |
| Nelson, Douglas | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/01/2022 |
| Nelson, Douglas | Individual | Trustee of the SNF | NOT APPLICABLE | 09/01/2022 |
| Nickerson, Kirby | Individual | Corporate Officer | NOT APPLICABLE | 10/01/2012 |
| Nickerson, Kirby | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2012 |
| Parrish, James | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/25/2022 |
| Parrish, James | Individual | ADP of the SNF | NOT APPLICABLE | 02/25/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "Does your facility have an active resident council, and how does management respond to its concerns?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Where do you post your daily staffing numbers, and can I see today's?"
- "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
- "What adaptive eating equipment do you provide, and how do you decide who needs help at meals?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Autumn Care of Myrtle Grove | 1.0 mi | Wilmington, NC | ★☆☆☆☆ | 1/5 | abuse |
| Azalea Health & Rehab Center | 3.0 mi | Wilmington, NC | ★★☆☆☆ | 2/5 | |
| August Healthcare at Wilmington | 4.3 mi | Wilmington, NC | ★★☆☆☆ | 3/5 | |
| Peak Resources-Wilmington, INC | 4.4 mi | Wilmington, NC | ★☆☆☆☆ | 1/5 | |
| Cypress Pointe Rehabilitation Center | 5.0 mi | Wilmington, NC | ★★★★★ | 5/5 | |
| Brunswick Cove Nursing Center | 6.3 mi | Winnabow, NC | ★★☆☆☆ | 3/5 | |
| Bradley Creek Health Center | 6.8 mi | Wilmington, NC | ★★★★★ | 5/5 | |
| Liberty Commons Rehabilitation Center | 7.0 mi | Wilmington, NC | ★★☆☆☆ | 2/5 | |
| Davis Health and Wellness Center at Cambridge Vill | 10.3 mi | Wilmington, NC | ★★☆☆☆ | 2/5 | |
| Northchase Nursing and Rehabilitation Center | 11.3 mi | Wilmington, NC | ★★☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 345554.