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.
4.24
Nurse hours/resident/day
Reported total nurse staffing hours per resident per day.
State Average: 3.8
55.3%
Nurse turnover
The percentage of nursing staff who stopped working at the home over a 12-month period.
State Average: 56.3%
100
Certified beds
Qualifying beds in the certified provider or supplier facility.
95
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
Lutheran Services For The Aging, Inc.
Indirect owners
No indirect owner information
Managerial control
Lsa Management, Inc. since Apr, 2007
Lutheran Services For The Aging, Inc. since Jun, 2011
Ted Goins since Apr, 2007
Lutheran Services For The Aging, Inc. since Jun, 2011
Ted Goins since Apr, 2007
Managing employee(s)
Ted Goins since Apr, 2007
Kesha Smith since Mar, 2011
Kesha Smith since Mar, 2011
Inspection Reports
17
total deficiencies
1
infection-related deficiency
This home violated federal standards protecting residents from the spread of infections.
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.
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
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
Some 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 a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0580
Failure to:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Infection Control Deficiency — F0885
Failure to:
Report COVID19 data to residents and families.
Severity
No actual harm, with potential for minimal harm
Scope
Many people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0641
Failure to:
Ensure each resident receives an accurate assessment.
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
Immediate jeopardy to resident health or safety
Scope
Few 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
Many 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
Some people affected
Seriousness
Resident Rights Deficiency — F0557
Failure to:
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
Failure to:
Respond appropriately to all alleged violations.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0637
Failure to:
Assess the resident when there is a significant change in condition
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0641
Failure to:
Ensure each resident receives an accurate assessment.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0572
Failure to:
Give residents a notice of rights, rules, services and charges.
Severity
No actual harm, with potential for minimal harm
Scope
Many people affected
Seriousness
Penalties
This home has no record of fines or payment suspensions for the past three years.