Cycle 1
Health 2025-09-18 · Fire 2024-10-10
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Wilmington, NC
Trinity Grove
3-star overall rating with 2-star inspections with abuse icon flag with $137,770 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
631 Junction Creek Drive, Wilmington, NC
(910) 442-3000
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
93
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lutheran Services Carolinas
Operator or chain grouping
Approved since
2011-06-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.96
Registered nurse staffing
LPN hours / resident day
0.70
Licensed practical nurse staffing
Aide hours / resident day
2.69
Nurse aide staffing
Weekend hours
3.86
Weekend nurse staffing
RN turnover
42%
Annual RN turnover
Total nurse turnover
46%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
91.5%
5.8 pts better
|
93.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.2% |
94.1%
2.9 pts worse
|
95.5%
4.3 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.6%
0.7 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 4.2% |
4.8%
0.6 pts better
|
11.4%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.2% |
7.2%
2 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 39.8% |
21.6%
18.2 pts worse
|
19.6%
20.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 17.3% |
15.0%
2.3 pts worse
|
16.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.9% |
21.5%
1.6 pts better
|
16.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.4% |
16.8%
1.6 pts worse
|
14.9%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.9%
About the same
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 4.4% |
2.6%
1.8 pts worse
|
1.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.8% |
21.2%
7.6 pts worse
|
19.8%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
6.0%
2 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.4% |
79.9%
3.5 pts worse
|
81.7%
5.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
13.2%
3.2 pts better
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.3% |
78.1%
2.2 pts better
|
79.7%
0.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.6% |
22.9%
2.3 pts better
|
23.9%
3.3 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-10 · Fire 2023-07-13
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-07-13 · Fire 2022-04-28
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-10
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-10-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-10-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-10-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-10-10
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-10-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-03
F · Potential for more than minimal harm
2023-07-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-20
F · Potential for more than minimal harm
2023-07-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-20
Inspection history
Recent health citations
G · Actual harm
2025-09-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-26
E · Potential for more than minimal harm
2025-09-18
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-10-08
E · Potential for more than minimal harm
2025-09-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-08
C · Minimal harm
2025-09-18
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-10-08
B · Minimal harm
2025-09-18
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2025-10-08
G · Actual harm
2024-10-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-10-10
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-10-10
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2024-10-30
K · Immediate jeopardy
2024-08-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-21
K · Immediate jeopardy
2024-08-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-11-21
D · Potential for more than minimal harm
2024-08-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-25
E · Potential for more than minimal harm
2023-07-13
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-08-15
E · Potential for more than minimal harm
2023-07-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-13
F811 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-08-15
E · Potential for more than minimal harm
2023-05-09
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-07-13
Penalties and ownership
What sits behind the stars
$99,600
2025-09-18
Fine
Fine · fine $99,600
Fine
$21,085
2024-10-10
Fine
Fine · fine $21,085
Fine
$8,542
2024-08-05
Fine
Fine · fine $8,542
Fine
$8,543
2024-08-05
Fine
Fine · fine $8,543
Fine
Ownership
Lutheran Services For The Aging, Inc.
5% Or Greater Direct Ownership Interest · Organization
Goins, Ted
Operational/Managerial Control · Individual
Lsa Management, Inc.
Operational/Managerial Control · Organization
Lutheran Home Wilmington Property, Inc
Operational/Managerial Control · Organization
Lutheran Services For The Aging, Inc.
Operational/Managerial Control · Organization
Maddry, Karen
Corporate Officer · Individual
Nickerson, Kirby
Corporate Officer · Individual
Parrish, James
Operational/Managerial Control · Individual
Smith, Kesha
Operational/Managerial Control · Individual
Smith, Kesha
Corporate Director · Individual
Sutton-Surak, Audrey
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Autumn Care of Myrtle Grove
Wilmington, NC
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $161,633 in total fines with 18 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Azalea Health & Rehab Center
Wilmington, NC
2-star overall rating with 2-star inspections with $24,470 in total fines with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
August Healthcare at Wilmington
Wilmington, NC
3-star overall rating with 3-star inspections with $27,378 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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