Trinity Grove
Non profit - Church related · 631 Junction Creek Drive, Wilmington, NC 28412 · See home’s Medicare page
Affiliated With Lutheran Services Carolinas
People or companies with an ownership interest in or managerial control of this home, according to CMS data.
4.21
Nurse hours/resident/day
Reported total nurse staffing hours per resident per day.
State Average: 3.8
44.1%
Nurse turnover
The percentage of nursing staff who stopped working at the home over a 12-month period.
State Average: 49.6%
100
Certified beds
Qualifying beds in the certified provider or supplier facility.
92
Average residents/day
Average number of residents based on daily census.
Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
Direct owners
No direct owner information
Indirect owners
No indirect owner information
Managerial control
Lsa Management, INC. since Apr, 2007
Lutheran Home Wilmington Property, INC since Apr, 1988
Lutheran Services For The Aging, INC. since Apr, 2007
Ted Goins since Nov, 2004
James Parrish since Feb, 2022
Kesha Smith since Oct, 2012
Audrey Sutton Surak since Feb, 2022
Lutheran Home Wilmington Property, INC since Apr, 1988
Lutheran Services For The Aging, INC. since Apr, 2007
Ted Goins since Nov, 2004
James Parrish since Feb, 2022
Kesha Smith since Oct, 2012
Audrey Sutton Surak since Feb, 2022
Managing employee(s)
No information available
Managing Control Governing Body
Ted Goins since Nov, 2004
Richard Herman since Jun, 2021
Douglas Nelson since Sep, 2022
Richard Herman since Jun, 2021
Douglas Nelson since Sep, 2022
Corporate Director
Kesha Smith since Sep, 2003
Corporate Officer
Karen Maddry since Apr, 2007
Kirby Nickerson since Oct, 2012
Kirby Nickerson since Oct, 2012
Trustee Of The Snf
Lutheran Services For The Aging, INC. since Apr, 2007
Ted Goins since Nov, 2004
Richard Herman since Jun, 2021
Douglas Nelson since Sep, 2022
Ted Goins since Nov, 2004
Richard Herman since Jun, 2021
Douglas Nelson since Sep, 2022
Adp Of The Snf
Lsa Management, INC. since Mar, 2025
Lutheran Home Wilmington Property, INC since Apr, 2025
Lutheran Services For The Aging, INC. since Apr, 2025
Ted Goins since Nov, 2004
Kirby Nickerson since Oct, 2012
James Parrish since Feb, 2022
Audrey Sutton Surak since Oct, 2012
Lutheran Home Wilmington Property, INC since Apr, 2025
Lutheran Services For The Aging, INC. since Apr, 2025
Ted Goins since Nov, 2004
Kirby Nickerson since Oct, 2012
James Parrish since Feb, 2022
Audrey Sutton Surak since Oct, 2012
Inspection Reports
Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
15
total deficiencies
1
infection-related deficiency
This home violated federal standards protecting residents from the spread of infections.
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
Failure to:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0565
Failure to:
Honor the resident's right to organize and participate in resident/family groups in the facility.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Infection Control Deficiency — F0880
Failure to:
Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Nursing and Physician Services Deficiency — F0732
Failure to:
Post nurse staffing information every day.
Severity
No actual harm, with potential for minimal harm
Scope
Many people affected
Seriousness
Resident Rights Deficiency — F0585
Failure to:
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.
Severity
No actual harm, with potential for minimal harm
Scope
Some people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
Failure to:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
Failure to:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Nutrition and Dietary Deficiency — F0810
Failure to:
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
Failure to:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity
Immediate jeopardy to resident health or safety
Scope
Some people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
Failure to:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity
Immediate jeopardy to resident health or safety
Scope
Some people affected
Seriousness
Quality of Life and Care Deficiency — F0684
Failure to:
Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0761
Failure to:
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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Nutrition and Dietary Deficiency — F0812
Failure to:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Rights Deficiency — F0550
Failure to:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Nutrition and Dietary Deficiency — F0811
Failure to:
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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Penalties
A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.
$103K
total fines