01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-09-18 | 5 | 2024-10-10 | 6 |
| Cycle 2 | 2024-10-10 | 6 | 2023-07-13 | 2 |
| Cycle 3 | 2023-07-13 | 4 | 2022-04-28 | 0 |
CMS CCN 3455542026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Trinity Grove
631 Junction Creek Drive · Wilmington, NC 28412 · New Hanover County
Certified beds100CMS provider file
Recent citation rows23current CMS citation release
Penalty rows4current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
23 rows in the current release
4 rows carry G–L scope/severity codes; 2 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-09-18 · HEALTHF0565Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
Correction field: Deficient, Provider has date of correction · 2025-10-082025-09-18 · HEALTHF0585Severity B · pattern; potential for minimal harm
Resident Rights Deficiencies
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.
Correction field: No revisit needed · 2025-10-082025-09-18 · HEALTHF0600Severity G · isolated actual harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-09-26 · complaint2025-09-18 · HEALTHF0732Severity C · widespread; potential for minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: No revisit needed · 2025-10-082025-09-18 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-10-082024-10-10 · HEALTHF0600Severity G · isolated actual harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2024-10-302024-10-10 · HEALTHF0607Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2024-10-302024-10-10 · HEALTHF0810Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Correction field: Deficient, Provider has date of correction · 2024-10-302024-10-10 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2024-12-032024-10-10 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-12-032024-10-10 · FIREK0521Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2024-12-032024-10-10 · FIREK0914Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Correction field: Deficient, Provider has date of correction · 2024-12-032024-10-10 · FIREK0916Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Correction field: Deficient, Provider has date of correction · 2024-12-032024-10-10 · FIREK0918Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2024-12-032024-08-05 · HEALTHF0600Severity K · pattern of immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Past Non-Compliance · 2023-11-21 · complaint2024-08-05 · HEALTHF0607Severity K · pattern of immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Past Non-Compliance · 2023-11-21 · complaint2024-08-05 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-08-25 · complaint2023-07-13 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2023-08-152023-07-13 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-08-152023-07-13 · HEALTHF0811Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-08-152023-07-13 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2023-08-152023-07-13 · FIREK0761Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2023-09-202023-07-13 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2023-09-2003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-09-18 | Fine | $64,740 | 0 |
| 2024-10-10 | Fine | $21,085 | 0 |
| 2024-08-05 | Fine | $8,542 | 0 |
| 2024-08-05 | Fine | $8,543 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- GOINS, TEDIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/04/2004
- HERMAN, RICHARDIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 06/01/2021
- NELSON, DOUGLASIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 09/01/2022
- SMITH, KESHAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/08/2003
- MADDRY, KARENIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/30/2007
- NICKERSON, KIRBYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 10/01/2012
- LSA MANAGEMENT, INC.Organization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/30/2007
- LUTHERAN HOME WILMINGTON PROPERTY, INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/05/1988
- LUTHERAN SERVICES FOR THE AGING, INC.Organization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/30/2007
- GOINS, TEDIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/04/2004
- PARRISH, JAMESIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/25/2022
- SMITH, KESHAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2012
- SUTTON-SURAK, AUDREYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/25/2022
- LUTHERAN SERVICES FOR THE AGING, INC.Organization · TRUSTEE OF THE SNFNOT APPLICABLE · since 04/30/2007
- GOINS, TEDIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 11/04/2004
- HERMAN, RICHARDIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 06/01/2021
- NELSON, DOUGLASIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 09/01/2022
- LSA MANAGEMENT, INC.Organization · ADP OF THE SNFNOT APPLICABLE · since 03/16/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.37per resident day
RN hours0.83per resident day
Weekend nurse hours3.85per resident day
Staff turnover45.5%CMS reported field
06 / LOCAL RECORDS
Open the Wilmington ledger →Other published facilities nearby
August Healthcare At Wilmington120 beds · CMS overall 2/543 citation rowsAutumn Care Of Myrtle Grove90 beds · CMS overall 1/552 citation rowsAzalea Health & Rehab Center80 beds · CMS overall 2/559 citation rowsBradley Creek Health Center30 beds · CMS overall 5/516 citation rowsCypress Pointe Rehabilitation Center90 beds · CMS overall 5/510 citation rowsDavis Health Care Center115 beds · CMS overall 1/523 citation rowsDavis Health And Wellness Center At Cambridge Vill20 beds · CMS overall 2/516 citation rowsLiberty Commons Rehabilitation Center82 beds · CMS overall 2/531 citation rows