Federal inspection record · CMS data as of October 1, 2026
Trinity Grove
631 Junction Creek Drive, Wilmington, NC · (910) 442-3000
- Cited for abuse (CMS abuse icon)
- Certified beds
- 100
- Residents per day
- 94
- Ownership
- Non-Profit
- Chain
- Lutheran Services Carolinas
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- June 29, 2011
1
How this home got 3 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in North Carolina.
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Staffing
★★★★★+1 star
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
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Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★3 of 5
Matches the rating CMS publishes on Care Compare.
This home carries CMS's abuse icon, which caps its inspection rating at 2 stars and so its overall rating at 4.
2
Where it sits among North Carolina homes
Trinity Grove carries 45 inspection points. That is fewer than 37% of North Carolina's 415 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in North Carolina: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–4 pts
- 4★ 4–15 pts
- 3★ 15–35 pts
- 2★ 35–73.5 pts
- 1★ over 73.5 pts
Bars show every rated home in North Carolina by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
15 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (4)
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G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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K
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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K
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Everything else, by area of care
Resident Rights3E
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
- B
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.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Nutrition and Dietary3E
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
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.
Infection Control1E
- E
Provide and implement an infection prevention and control program.
Nursing and Physician Services1C
- C
Post nurse staffing information every day.
Freedom from Abuse, Neglect, and Exploitation1D
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Quality of Life and Care1D
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Pharmacy Service1E
- E
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.
Inspection history
2025-09-18
5 health deficiencies · 6 fire-safety deficiencies
Top issue: Resident Rights (2 deficiencies)
2024-10-10
3 health deficiencies · 2 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2023-07-13
7 health deficiencies · 0 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 17 min of nursing staff time a day, 50 min of it from a registered nurse.
This home
4 h 17 min
North Carolina average
3 h 52 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 47% of nursing staff and 36% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$102,910 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-09-18 | Fine | $64,740 |
| 2024-10-10 | Fine | $21,085 |
| 2024-08-05 | Fine | $8,542 |
| 2024-08-05 | Fine | $8,543 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.7 pts better | 1.0 | 1.7 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.3 pts worse | 2.0 | 1.7 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine7.3 pts better | 99.7% | 92.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine5.3 pts better | 100.0% | 94.7% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury3.9 pts worse | 7.3% | 3.4% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms4.7 pts better | 2.1% | 6.8% | 13.5% |
| Percentage of long-stay residents who lose too much weight2.5 pts worse | 9.6% | 7.1% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication18.4 pts worse | 39.5% | 21.1% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication1.1 pts worse | 15.0% | 13.9% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened0.4 pts worse | 17.0% | 16.6% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased1.9 pts worse | 16.9% | 15.0% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.6 pts better | 0.0% | 0.6% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection2.3 pts worse | 4.4% | 2.1% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence2.2 pts worse | 22.1% | 19.9% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.6 pts better | 4.8% | 5.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine1.1 pts worse | 80.4% | 81.5% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit0.8 pts worse | 13.5% | 12.7% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.8 pts better | 0.6% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine7.1 pts better | 88.2% | 81.1% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission2.1 pts better | 20.1% | 22.2% | 23.4% |
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Who owns and runs it
24 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Goins, Ted | Managing Control - Governing Body · Individual | 0% | 9 facilities |
| Goins, Ted | Operational/Managerial Control · Individual | 0% | 9 facilities |
| Goins, Ted | Trustee Of The SNF · Individual | 0% | 9 facilities |
| Goins, Ted | Adp Of The SNF · Individual | 0% | 9 facilities |
| Herman, Richard | Managing Control - Governing Body · Individual | 0% | 9 facilities |
| Herman, Richard | Trustee Of The SNF · Individual | 0% | 9 facilities |
| Lsa Management, Inc. | Operational/Managerial Control · Organization | 0% | 7 facilities |
| Lsa Management, Inc. | Adp Of The SNF · Organization | 0% | 7 facilities |
| Lutheran Home Wilmington Property, Inc | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Lutheran Home Wilmington Property, Inc | Adp Of The SNF · Organization | 0% | 1 facilities |
| Lutheran Services For The Aging, Inc. | Operational/Managerial Control · Organization | 0% | 9 facilities |
| Lutheran Services For The Aging, Inc. | Trustee Of The SNF · Organization | 0% | 9 facilities |
| Lutheran Services For The Aging, Inc. | Adp Of The SNF · Organization | 0% | 9 facilities |
| Maddry, Karen | Corporate Officer · Individual | 0% | 9 facilities |
| Nelson, Douglas | Managing Control - Governing Body · Individual | 0% | 10 facilities |
| Nelson, Douglas | Trustee Of The SNF · Individual | 0% | 10 facilities |
| Nickerson, Kirby | Corporate Officer · Individual | 0% | 9 facilities |
| Nickerson, Kirby | Adp Of The SNF · Individual | 0% | 9 facilities |
| Parrish, James | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Parrish, James | Adp Of The SNF · Individual | 0% | 1 facilities |
| Smith, Kesha | Corporate Director · Individual | 0% | 9 facilities |
| Smith, Kesha | Operational/Managerial Control · Individual | 0% | 9 facilities |
| Sutton-Surak, Audrey | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Sutton-Surak, Audrey | Adp Of The SNF · Individual | 0% | 2 facilities |
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Fire safety
8 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Gas, Vacuum, and Electrical Systems4F
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- D
Have a battery powered remote alarm panel in a location accessible by operating personnel.
- D
Have generator or other power source capable of supplying service within 10 seconds.
- F
Have generator or other power source capable of supplying service within 10 seconds.
Smoke2D
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Inspect, test, and maintain automatic sprinkler systems.
Services1D
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Miscellaneous1F
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
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Other homes nearby
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Autumn Care of Myrtle Grove
Wilmington, NC · Saber Healthcare Group · Abuse icon
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 4 h 6 min
- Fines
- $141,604
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Azalea Health & Rehab Center
Wilmington, NC · Saber Healthcare Group
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 36 min
- Fines
- $24,470
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August Healthcare at Wilmington
Wilmington, NC · August Healthcare
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 6 min
- Fines
- $27,378