Nursing homes › North Carolina › Trinity Grove
631 Junction Creek Drive, Wilmington, NC 28412 · 9104423000 · 100 certified beds
Per CMS filings, this facility is affiliated with Lutheran Services Carolinas, a group operating 9 facilities in 1 states. Group record: average rating 4.2/5, 1 abuse citation icons, 0 facilities on the Special Focus list, $150,545 in federal fines. This facility rates below its group average (4.2/5).
Total nurse staffing: 4.37 (North Carolina median: 3.53). RN hours: 0.83. Weekend total: 3.85. Nursing staff turnover: 46%.
All-time on record: 15 deficiency citations, including 2 at immediate-jeopardy level. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2025-09-18 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | complaint | corrected 2025-09-26 |
| 2025-09-18 | Honor the resident's right to organize and participate in resident/family groups in the facility. | E | Health | corrected 2025-10-08 |
| 2025-09-18 | Provide and implement an infection prevention and control program. | E | Health | corrected 2025-10-08 |
| 2025-09-18 | Post nurse staffing information every day. | C | Health | corrected 2025-10-08 |
| 2025-09-18 | 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. | B | Health | corrected 2025-10-08 |
| 2024-10-10 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | Health | corrected 2024-10-30 |
| 2024-10-10 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | Health | corrected 2024-10-30 |
| 2024-10-10 | Provide special eating equipment and utensils for residents who need them and appropriate assistance. | D | Health | corrected 2024-10-30 |
| 2024-08-05 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | K | complaint | corrected 2023-11-21 |
| 2024-08-05 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | K | complaint | corrected 2023-11-21 |
| 2024-08-05 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | complaint | corrected 2024-08-25 |
| 2023-07-13 | 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. | E | Health | corrected 2023-08-15 |
| 2023-07-13 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Health | corrected 2023-08-15 |
| 2023-07-13 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Health | corrected 2023-08-15 |
| 2023-07-13 | 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. | D | Health | corrected 2023-08-15 |
| Date | Type | 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 |
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| GOINS, TED | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 11/04/2004 |
| HERMAN, RICHARD | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 06/01/2021 |
| NELSON, DOUGLAS | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 09/01/2022 |
| SMITH, KESHA | Corporate Director | Individual | NOT APPLICABLE | since 09/08/2003 |
| MADDRY, KAREN | Corporate Officer | Individual | NOT APPLICABLE | since 04/30/2007 |
| NICKERSON, KIRBY | Corporate Officer | Individual | NOT APPLICABLE | since 10/01/2012 |
| LSA MANAGEMENT, INC. | Operational/Managerial Control | Organization | NOT APPLICABLE | since 04/30/2007 |
| LUTHERAN HOME WILMINGTON PROPERTY, INC | Operational/Managerial Control | Organization | NOT APPLICABLE | since 04/05/1988 |
| LUTHERAN SERVICES FOR THE AGING, INC. | Operational/Managerial Control | Organization | NOT APPLICABLE | since 04/30/2007 |
| GOINS, TED | Operational/Managerial Control | Individual | NOT APPLICABLE | since 11/04/2004 |
| PARRISH, JAMES | Operational/Managerial Control | Individual | NOT APPLICABLE | since 02/25/2022 |
| SMITH, KESHA | Operational/Managerial Control | Individual | NOT APPLICABLE | since 10/01/2012 |
| SUTTON-SURAK, AUDREY | Operational/Managerial Control | Individual | NOT APPLICABLE | since 02/25/2022 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 345554. Corrections: data@carerecords.org.