Home › North Carolina › New Hanover County › Trinity Grove
Trinity Grove
631 Junction Creek Drive, Wilmington, NC 28412 · CMS Certification Number (CCN) 345554
CMS abuse icon
CMS shows the abuse icon when a nursing home was cited for abuse or neglect at the harm level or above (scope/severity G or higher) on its most recent inspection cycle, or at the potential-harm level (D or higher) on both of its two most recent cycles. CMS data dictionary
At a glance
- CMS overall rating
- ★★★☆☆ 3 of 5
- Health inspection citations
- 15 in the last 3 inspection cycles (2 immediate jeopardy, 2 actual harm, 4 from complaints)
- Fire safety citations
- 8
- Fines (last 3 years)
- 4 fines, total $102,910
- Payment denials
- 0
- Most recent standard inspection
- September 18, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Overall | ★★★☆☆ 3 of 5 | 2.9 | 3 |
| Health inspections | ★★☆☆☆ 2 of 5 | 2.9 | 2.8 |
| Staffing | ★★★★★ 5 of 5 | 2.7 | 2.9 |
| Quality measures | ★★★☆☆ 3 of 5 | 3.3 | 3.6 |
| Long-stay quality | ★★☆☆☆ 2 of 5 | Not published | Not published |
| Short-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | September 18, 2025 | 5 | 5 | 1 |
| Cycle 2 | October 10, 2024 | 6 | 3 | 3 |
CMS weighted health inspection score: 45 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
15 health citations across 4 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
September 18, 2025: 5 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2025 |
| C | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies | Standard | No revisit needed Corrected 10/08/2025 |
| G | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 09/26/2025 |
| B | F-0585 | Honor 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. Resident Rights Deficiencies | Standard | No revisit needed Corrected 10/08/2025 |
| E | F-0565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2025 |
October 10, 2024: 3 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0810 | Provide special eating equipment and utensils for residents who need them and appropriate assistance. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/30/2024 |
| D | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/30/2024 |
| G | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/30/2024 |
August 5, 2024: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 08/25/2024 |
| K | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Past Non-Compliance Corrected 11/21/2023 |
| K | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Past Non-Compliance Corrected 11/21/2023 |
July 13, 2023: 4 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/15/2023 |
| D | F-0811 | Ensure 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. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/15/2023 |
| E | F-0761 | 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 | Standard | Deficient, Provider has date of correction Corrected 08/15/2023 |
| D | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/15/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
8 fire safety citations across 2 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 10/10/2024 | D | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 12/03/2024 |
| 10/10/2024 | D | K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 12/03/2024 |
| 10/10/2024 | E | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 12/03/2024 |
| 10/10/2024 | D | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 12/03/2024 |
| 10/10/2024 | D | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 12/03/2024 |
| 10/10/2024 | D | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 12/03/2024 |
| 07/13/2023 | F | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 09/20/2023 |
| 07/13/2023 | F | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 09/20/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| September 18, 2025 | Fine | $64,740 | — |
| October 10, 2024 | Fine | $21,085 | — |
| August 5, 2024 | Fine | $8,542 | — |
| August 5, 2024 | Fine | $8,543 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 4.37 | 3.85 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.83 | 0.62 | 0.69 |
| LPN/LVN hours per resident per day | 0.79 | Not published | Not published |
| Nurse aide hours per resident per day | 2.75 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.85 | Not published | Not published |
| RN hours per resident per day, weekends | 0.42 | Not published | Not published |
| Total nursing staff turnover (%) | 45.5 | 49 | 45.8 |
| Registered nurse turnover (%) | 30.8 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Lutheran Home - Wilmington, INC.
- Ownership type
- Non profit - Church related
- Chain
- Lutheran Services Carolinas (9 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 100
- Average residents per day
- 94.9
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- Yes
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- June 29, 2011
- County/parish
- New Hanover
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
24 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| GOINS, TED | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HERMAN, RICHARD | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NELSON, DOUGLAS | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SMITH, KESHA | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MADDRY, KAREN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NICKERSON, KIRBY | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LSA MANAGEMENT, INC. | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| LUTHERAN HOME WILMINGTON PROPERTY, INC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| LUTHERAN SERVICES FOR THE AGING, INC. | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| GOINS, TED | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| PARRISH, JAMES | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SMITH, KESHA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SUTTON-SURAK, AUDREY | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LUTHERAN SERVICES FOR THE AGING, INC. | TRUSTEE OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| GOINS, TED | TRUSTEE OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HERMAN, RICHARD | TRUSTEE OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NELSON, DOUGLAS | TRUSTEE OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LSA MANAGEMENT, INC. | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| LUTHERAN HOME WILMINGTON PROPERTY, INC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| LUTHERAN SERVICES FOR THE AGING, INC. | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| GOINS, TED | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NICKERSON, KIRBY | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| PARRISH, JAMES | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SUTTON-SURAK, AUDREY | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Trinity Grove. Full inspection reports, quality measures and staffing.
- DHSR Complaint Intake Unit: File a Complaint. The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.