# Trinity Grove

Trinity Grove is a Medicare/Medicaid-certified nursing home (Nursing home · SNF / NF) in Wilmington, NC, CMS Certification Number 345554, with 100 certified beds and about 94 residents per day. CMS rates it 3/5 overall (health inspections 2/5, staffing 5/5, quality measures 4/5).

## Key facts
- Status: Active CMS certification
- Address: 631 Junction Creek Drive, Wilmington, NC 28412 (New Hanover County)
- Ownership type: Non profit - Church related

- Operator (legal business name): [Lutheran Home - Wilmington, Inc](https://carefield.site/operator/op-lutheran-home-wilmington-inc)
- CMS chain: [Lutheran Services Carolinas](https://carefield.site/chain/cms-chain-327) — 9 facilities

- CMS abuse icon: yes (cited for abuse in the recent window)

- Phone: 9104423000
- Medicare Care Compare: https://www.medicare.gov/care-compare/details/nursing-home/345554

## Inspection record
7 inspections in the CMS window (latest 2025-09-18); 23 citations (15 health, 8 fire safety); 2 at actual harm and 2 at immediate jeopardy; 0 without a verified correction at last report. CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years; no citation in that window is not proof of a clean history.
- 2024-08-05 — [F-0600](https://carefield.site/deficiency/cms-f0600) Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. — scope/severity K (Immediate jeopardy to resident health or safety); Past non-compliance; complaint survey
- 2024-08-05 — [F-0607](https://carefield.site/deficiency/cms-f0607) Develop and implement policies and procedures to prevent abuse, neglect, and theft. — scope/severity K (Immediate jeopardy to resident health or safety); Past non-compliance; complaint survey
- 2025-09-18 — [F-0600](https://carefield.site/deficiency/cms-f0600) Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. — scope/severity G (Actual harm (not immediate jeopardy)); Corrected; complaint survey
- 2024-10-10 — [F-0600](https://carefield.site/deficiency/cms-f0600) Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. — scope/severity G (Actual harm (not immediate jeopardy)); Corrected
- 2025-09-18 — [F-0565](https://carefield.site/deficiency/cms-f0565) Honor the resident's right to organize and participate in resident/family groups in the facility. — scope/severity E (No actual harm, potential for more than minimal harm); Corrected
- 2025-09-18 — [F-0880](https://carefield.site/deficiency/cms-f0880) Provide and implement an infection prevention and control program. — scope/severity E (No actual harm, potential for more than minimal harm); Corrected
- 2024-10-10 — [K-0321](https://carefield.site/deficiency/cms-k0321) Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected
- 2024-10-10 — [K-0353](https://carefield.site/deficiency/cms-k0353) Inspect, test, and maintain automatic sprinkler systems. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected
- 2024-10-10 — [K-0521](https://carefield.site/deficiency/cms-k0521) Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected
- 2024-10-10 — [K-0914](https://carefield.site/deficiency/cms-k0914) Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. — scope/severity E (No actual harm, potential for more than minimal harm); Corrected
- 2024-10-10 — [K-0916](https://carefield.site/deficiency/cms-k0916) Have a battery powered remote alarm panel in a location accessible by operating personnel. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected
- 2024-10-10 — [K-0918](https://carefield.site/deficiency/cms-k0918) Have generator or other power source capable of supplying service within 10 seconds. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected
- 2024-10-10 — [F-0607](https://carefield.site/deficiency/cms-f0607) Develop and implement policies and procedures to prevent abuse, neglect, and theft. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected
- 2024-10-10 — [F-0810](https://carefield.site/deficiency/cms-f0810) Provide special eating equipment and utensils for residents who need them and appropriate assistance. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected
- 2024-08-05 — [F-0684](https://carefield.site/deficiency/cms-f0684) Provide appropriate treatment and care according to orders, resident’s preferences and goals. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected; complaint survey
- 2023-07-13 — [K-0761](https://carefield.site/deficiency/cms-k0761) To conduct inspection, testing and maintenance of fire doors by qualified individuals. — scope/severity F (No actual harm, potential for more than minimal harm); Corrected
- 2023-07-13 — [K-0918](https://carefield.site/deficiency/cms-k0918) Have generator or other power source capable of supplying service within 10 seconds. — scope/severity F (No actual harm, potential for more than minimal harm); Corrected
- 2023-07-13 — [F-0550](https://carefield.site/deficiency/cms-f0550) Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected
- 2023-07-13 — [F-0761](https://carefield.site/deficiency/cms-f0761) 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. — scope/severity E (No actual harm, potential for more than minimal harm); Corrected
- 2023-07-13 — [F-0811](https://carefield.site/deficiency/cms-f0811) 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. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected
- …and 3 more on the source page.

## Penalties
- 2025-09-18 — Civil money penalty (fine): $64,740
- 2024-10-10 — Civil money penalty (fine): $21,085
- 2024-08-05 — Civil money penalty (fine): $8,543
- 2024-08-05 — Civil money penalty (fine): $8,542

## Staffing (PBJ, hours per resident per day)
- Total nurse: 4.28968 (state avg 3.87089, US 3.90085)
- RN: 0.83864
- Nursing staff turnover: 47.1%

## Owners and managers of record (CMS disclosures)
- Ted Goins — Operational / managerial control, since 2004-11-04
- Richard Herman — Operational / managerial control, since 2021-06-01
- Douglas Nelson — Operational / managerial control, since 2022-09-01
- [Lsa Management, Inc](https://carefield.site/owner/org-lsa-management-inc) — Operational / managerial control, since 2007-04-30
- [Lutheran Home Wilmington Property, Inc](https://carefield.site/owner/org-lutheran-home-wilmington-property-inc) — Operational / managerial control, since 1988-04-05
- [Lutheran Services for the Aging, Inc](https://carefield.site/owner/org-lutheran-services-for-the-aging-inc) — Operational / managerial control, since 2007-04-30
- Ted Goins — Operational / managerial control, since 2004-11-04
- James Parrish — Operational / managerial control, since 2022-02-25
- Kesha Smith — Operational / managerial control, since 2012-10-01
- Audrey Sutton-Surak — Operational / managerial control, since 2022-02-25

## Nearby nursing homes
- [Autumn Care of Myrtle Grove](https://carefield.site/facility/cms-345507) — 1.5 km, CMS overall 1/5
- [Azalea Health & Rehab Center](https://carefield.site/facility/cms-345557) — 4.8 km, CMS overall 2/5
- [August Healthcare at Wilmington](https://carefield.site/facility/cms-345236) — 6.9 km, CMS overall 2/5
- [Peak Resources-Wilmington, Inc](https://carefield.site/facility/cms-345537) — 7.1 km, CMS overall 1/5
- [Cypress Pointe Rehabilitation Center](https://carefield.site/facility/cms-345002) — 8.1 km, CMS overall 5/5
- [Brunswick Cove Nursing Center](https://carefield.site/facility/cms-345318) — 10.1 km, CMS overall 3/5
- [Bradley Creek Health Center](https://carefield.site/facility/cms-345571) — 10.9 km, CMS overall 5/5
- [Liberty Commons Rehabilitation Center](https://carefield.site/facility/cms-345468) — 11.3 km, CMS overall 2/5

## Sources
- cms_provider_info: https://data.cms.gov/provider-data/api/1/datastore/query/4pq5-n9py/0?conditions%5B0%5D%5Bproperty%5D=cms_certification_number_ccn&conditions%5B0%5D%5Bvalue%5D=345554&conditions%5B0%5D%5Boperator%5D=%3D
- cms_ownership: https://data.cms.gov/provider-data/api/1/datastore/query/y2hd-n93e/0?conditions%5B0%5D%5Bproperty%5D=cms_certification_number_ccn&conditions%5B0%5D%5Bvalue%5D=345554&conditions%5B0%5D%5Boperator%5D=%3D
- cms_health_deficiencies: https://data.cms.gov/provider-data/api/1/datastore/query/r5ix-sfxw/0?conditions%5B0%5D%5Bproperty%5D=cms_certification_number_ccn&conditions%5B0%5D%5Bvalue%5D=345554&conditions%5B0%5D%5Boperator%5D=%3D
- cms_fire_safety_deficiencies: https://data.cms.gov/provider-data/api/1/datastore/query/ifjz-ge4w/0?conditions%5B0%5D%5Bproperty%5D=cms_certification_number_ccn&conditions%5B0%5D%5Bvalue%5D=345554&conditions%5B0%5D%5Boperator%5D=%3D
- cms_penalties: https://data.cms.gov/provider-data/api/1/datastore/query/g6vv-u9sr/0?conditions%5B0%5D%5Bproperty%5D=cms_certification_number_ccn&conditions%5B0%5D%5Bvalue%5D=345554&conditions%5B0%5D%5Boperator%5D=%3D
- cms_inspection_dates: https://data.cms.gov/provider-data/api/1/datastore/query/svdt-c123/0?conditions%5B0%5D%5Bproperty%5D=cms_certification_number_ccn&conditions%5B0%5D%5Bvalue%5D=345554&conditions%5B0%5D%5Boperator%5D=%3D

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Source page: https://carefield.site/facility/cms-345554 · Carefield — Senior Care Intelligence. Facts come from the CMS Provider Data Catalog (Medicare/Medicaid-certified nursing homes). Missing data never means no issue exists.