Trinity Grove
Wilmington, New Hanover County, North Carolina · CCN 345554 · Non-profit (Church related) · part of Lutheran Services Carolinas (9 facilities, chain average 4.2 stars)
CMS rates Trinity Grove 3 of 5 overall as of August 2026. 100 certified beds, 95 residents a day on average. 15 citations on record from the current inspection cycles, 2 at immediate jeopardy; 4 fines totalling $102,910.
On record
- Abuse icon. CMS marks this facility for a citation of abuse that led to harm, or a repeated potential for it, within the recent inspection cycles.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★★☆☆ 3 of 5 |
|---|---|
| Health inspections | ★★☆☆☆ 2 of 5 |
| Staffing | ★★★★★ 5 of 5 |
| Quality measures | ★★★☆☆ 3 of 5 |
| Quality: long-stay / short-stay | 2 / 4 of 5 |
Staffing
| Total nurse staffing | 4.36717 hours per resident per day |
|---|---|
| Registered nurses | 0.8289 hours per resident per day |
| Weekend total | 3.85072 hours per resident per day |
| Nursing staff turnover | 45.5% (registered nurses 30.8%) |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2025-09-18 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2025-09-26 |
| 2025-09-18 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · tag F0565 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-10-08 |
| 2025-09-18 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-10-08 |
| 2025-09-18 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · tag F0732 |
C No actual harm, with potential for minimal harm; widespread | No revisit needed 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. Resident Rights Deficiencies · tag F0585 |
B No actual harm, with potential for minimal harm; pattern | No revisit needed 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. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-10-30 |
| 2024-10-10 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-30 |
| 2024-10-10 | Provide special eating equipment and utensils for residents who need them and appropriate assistance. Nutrition and Dietary Deficiencies · tag F0810 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-30 |
| 2024-08-05 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
K Immediate jeopardy to resident health or safety; pattern | Past Non-Compliance 2023-11-21 |
| 2024-08-05 complaint survey |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
K Immediate jeopardy to resident health or safety; pattern | Past Non-Compliance 2023-11-21 |
| 2024-08-05 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Pharmacy Service Deficiencies · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Nutrition and Dietary Deficiencies · tag F0811 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-15 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2025-09-18 | Fine | $64,740 |
| 2024-10-10 | Fine | $21,085 |
| 2024-08-05 | Fine | $8,543 |
| 2024-08-05 | Fine | $8,542 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Lsa Management, Inc. Organization | adp of the snf | — | 2025-03-16 |
| Lutheran Home Wilmington Property, Inc. Organization | adp of the snf | — | 2025-04-14 |
| Lutheran Services For The Aging, Inc. Organization | adp of the snf | — | 2025-04-25 |
| Lsa Management, Inc. Organization | operational/managerial control | — | 2007-04-30 |
| Lutheran Home Wilmington Property, Inc. Organization | operational/managerial control | — | 1988-04-05 |
| Lutheran Services For The Aging, Inc. Organization | operational/managerial control | — | 2007-04-30 |
| Lutheran Services For The Aging, Inc. Organization | trustee of the snf | — | 2007-04-30 |
| Goins, Ted Individual | adp of the snf | — | 2004-11-04 |
| Nickerson, Kirby Individual | adp of the snf | — | 2012-10-01 |
| Parrish, James Individual | adp of the snf | — | 2022-02-25 |
| Sutton-Surak, Audrey Individual | adp of the snf | — | 2012-10-01 |
| Smith, Kesha Individual | corporate director | — | 2003-09-08 |
| Maddry, Karen Individual | corporate officer | — | 2007-04-30 |
| Nickerson, Kirby Individual | corporate officer | — | 2012-10-01 |
| Goins, Ted Individual | managing control - governing body | — | 2004-11-04 |
| Herman, Richard Individual | managing control - governing body | — | 2021-06-01 |
| Nelson, Douglas Individual | managing control - governing body | — | 2022-09-01 |
| Goins, Ted Individual | operational/managerial control | — | 2004-11-04 |
| Parrish, James Individual | operational/managerial control | — | 2022-02-25 |
| Smith, Kesha Individual | operational/managerial control | — | 2012-10-01 |
| Sutton-Surak, Audrey Individual | operational/managerial control | — | 2022-02-25 |
| Goins, Ted Individual | trustee of the snf | — | 2004-11-04 |
| Herman, Richard Individual | trustee of the snf | — | 2021-06-01 |
| Nelson, Douglas Individual | trustee of the snf | — | 2022-09-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Trinity Grove.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in New Hanover County.