Nursing homeActive
Trinity Grove
631 Junction Creek Drive, Wilmington, NC 284129104423000100 certified beds · 95 residentsNon profit - Church relatedMedicare and Medicaid
Surveys on file
4
since 2023
Deficiencies
15
● 2● 9● 4
Penalties · 3 yrs
$102,910
4 fines
Last survey
2025-09-18
Standard
CMS overall
3 / 5
stars as published by CMS
CMS overall 3/5
Health 2
Staffing 5
Quality 3
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · North Carolina Division of Health Service Regulation · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2025-09-18 | Standard | 221 | CMS-2567 (Care Compare) | — |
| 2024-10-10 | Standard | 021 | CMS-2567 (Care Compare) | — |
| 2024-08-05 | Complaint | 012 | CMS-2567 (Care Compare) | — |
| 2023-07-13 | Standard | 040 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · North Carolina Division of Health Service Regulation publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity GHarm
Abuse & neglect
Isolated; actual harm that is not immediate jeopardy.Corrected 2025-09-26Record 345554-20250918-F600
F565Honor the resident's right to organize and participate in resident/family groups in the facility.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-10-08Record 345554-20250918-F565
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-10-08Record 345554-20250918-F880
F585Honor 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.Scope/severity BPaperwork
Dignity & rights
Pattern; potential for minimal harm.Corrected 2025-10-08Record 345554-20250918-F585
F732Post nurse staffing information every day.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2025-10-08Record 345554-20250918-F732
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity GHarm
Abuse & neglect
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-10-30Record 345554-20241010-F600
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-30Record 345554-20241010-F607
F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-30Record 345554-20241010-F810
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity KHarm
Abuse & neglect
Pattern; immediate jeopardy to resident health or safety.Corrected 2023-11-21Record 345554-20240805-F600
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity KHarm
Abuse & neglect
Pattern; immediate jeopardy to resident health or safety.Corrected 2023-11-21Record 345554-20240805-F607
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-25Record 345554-20240805-F684
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-15Record 345554-20230713-F550
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-15Record 345554-20230713-F761
F811Ensure 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.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-15Record 345554-20230713-F811
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-15Record 345554-20230713-F812
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2025-09-18 | Civil money penalty | $64,740 | CMS · Penalties |
| 2024-10-10 | Civil money penalty | $21,085 | CMS · Penalties |
| 2024-08-05 | Civil money penalty | $8,542 | CMS · Penalties |
| 2024-08-05 | Civil money penalty | $8,543 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.83
Facility
North Carolina
National
North Carolina 0.61 · National 0.69
Total nurse hours per resident day4.37
Facility
North Carolina
National
North Carolina 3.83 · National 3.86
Weekend total nurse hours3.85
Facility
North Carolina
National
North Carolina 3.40 · National 3.42
Total nursing staff turnover46%
Facility
North Carolina
National
North Carolina 49% · National 46%
Registered nurse turnover31%
Facility
North Carolina
National
North Carolina 46% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | North Carolina | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 6.3% | 5.5% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 7.6% | 3.5% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 15.8% | 14.0% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 5.7% | 2.3% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 17.6% | 15.6% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 11.2% | 7.2% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 38.8% | 21.3% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Goins, Ted Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Lsa Management, Inc. Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Lutheran Home Wilmington Property, Inc Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Lutheran Services For The Aging, Inc. Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Parrish, James Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Smith, Kesha Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Sutton-Surak, Audrey Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Goins, Ted Individual | TRUSTEE OF THE SNF | NOT APPLICABLE | — | — |
| Goins, Ted Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Goins, Ted Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Herman, Richard Individual | TRUSTEE OF THE SNF | NOT APPLICABLE | — | — |
| Herman, Richard Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Lsa Management, Inc. Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Lutheran Home Wilmington Property, Inc Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Lutheran Services For The Aging, Inc. Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Lutheran Services For The Aging, Inc. Organization | TRUSTEE OF THE SNF | NOT APPLICABLE | — | — |
| Maddry, Karen Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Nelson, Douglas Individual | TRUSTEE OF THE SNF | NOT APPLICABLE | — | — |
| Nelson, Douglas Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Nickerson, Kirby Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Nickerson, Kirby Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Parrish, James Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Smith, Kesha Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Sutton-Surak, Audrey Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
Lutheran Services Carolinas — 9 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or North Carolina.
No county cost figures on file for New Hanover.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Autumn Care of Myrtle Grove Wilmington | 1.0 mi | 2025-12-03 | 0229 |
| Azalea Health & Rehab Center Wilmington | 3.0 mi | 2025-05-30 | 3182 |
| August Healthcare at Wilmington Wilmington | 4.3 mi | 2025-05-15 | 2171 |
| Peak Resources-Wilmington, Inc Wilmington | 4.4 mi | 2026-05-22 | 3273 |
| Cypress Pointe Rehabilitation Center Wilmington | 5.0 mi | 2026-05-07 | 030 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |