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Trinity Grove

631 Junction Creek Drive, Wilmington, NC 28412
9104423000
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Overall CMS Rating

3.0/5

vs State Average: 2.9 stars

2.0/5

Health Inspections

vs State Average: 2.9/5

5.0/5

Staffing Level

vs State Average: 2.7/5

3.0/5

Quality Measures

vs State Average: 3.2/5

4 penalties in last 3 years
Penalties
vs State Average: 1.6 penalties

About This Facility

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Ratings Deep Dive

Score
2.0
State Average
2.9
National Average
2.8
5 Deficiencies found in last inspections
4 Penalties in last 3 years
4 Fines issued
Citation Date Description Severity
Sep 18, 2025 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
Sep 18, 2025 Post nurse staffing information every day. C
Sep 18, 2025 Provide and implement an infection prevention and control program. E
Sep 18, 2025 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. G
Sep 18, 2025 Honor the resident's right to organize and participate in resident/family groups in the facility. E
Score
5.0
State Average
2.7
National Average
2.9
1.0 RN Hours / Resident / Day
4.4 Total Nurse Hours / Resident / Day
41.7% RN Turnover Rate
Score
3.0
State Average
3.2
National Average
3.6
2.0 Long-Stay QM Rating
4.0 Short-Stay QM Rating
93.1 Avg Residents Per Day
Measure Score Type
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay
Percentage of long-stay residents who lose too much weight Long Stay
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay
Percentage of long-stay residents with a urinary tract infection Long Stay
Percentage of long-stay residents who have depressive symptoms Long Stay
Percentage of long-stay residents who were physically restrained Long Stay
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Long Stay
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Short Stay
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay

Ownership & Compliance

Ownership Info
5% OR GREATER DIRECT OWNERSHIP INTEREST LUTHERAN SERVICES FOR THE AGING, INC.
OPERATIONAL/MANAGERIAL CONTROL LSA MANAGEMENT, INC.
OPERATIONAL/MANAGERIAL CONTROL LUTHERAN HOME WILMINGTON PROPERTY, INC
OPERATIONAL/MANAGERIAL CONTROL LUTHERAN SERVICES FOR THE AGING, INC.
OPERATIONAL/MANAGERIAL CONTROL GOINS, TED
OPERATIONAL/MANAGERIAL CONTROL PARRISH, JAMES
OPERATIONAL/MANAGERIAL CONTROL SMITH, KESHA
OPERATIONAL/MANAGERIAL CONTROL SUTTON-SURAK, AUDREY
CORPORATE DIRECTOR SMITH, KESHA
CORPORATE OFFICER MADDRY, KAREN
Recent Penalties
Date Type Fine
Sep 18, 2025 Fine $99,600
Oct 10, 2024 Fine $21,085
Aug 5, 2024 Fine $8,542
Aug 5, 2024 Fine $8,543

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