| Trinity Grove | |
| 631 Junction Creek Drive, Wilmington, North Carolina 28412 | |
| (910) 442-3000 | |
| Name | Trinity Grove |
|---|---|
| Location | 631 Junction Creek Drive, Wilmington, North Carolina |
| Certified By | Medicare and Medicaid |
| No. of Certified Beds | 100 |
| Occupancy Rate | 94.9% |
| Medicare ID (CCN) | 345554 |
| Legal Business Name | Lutheran Home - Wilmington, Inc. |
| Ownership Type | Non Profit - Church Related |
| Chain | Lutheran Services Carolinas (9 nursing homes) |
| Chain Average Overall Rating | 4.2 out of 5 |
| NPI Number | 1194028118 |
| Match | Confirmed listed in Medicare enrollment records |
| Organization Name | Lutheran Home - Wilmington, Inc. |
| Doing Business As | Trinity Grove |
| Address | 631 Junction Creek Drive, Wilmington, NC 28412 |
| Phone Number | 910-465-6861 |
| Ratings from Surveys (Inspections): | |
| Ratings from Quality Measures: | |
| Ratings from Staffing Data: | |
| Overall Rating: |
|---|
| Staffing Measure | Provider | National Avg. |
|---|---|---|
| Total nurse staff hours per resident per day | 4.37 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.83 | 0.69 |
| Licensed practical nurse (LPN) hours per resident per day | 0.79 | 0.86 |
| Nurse aide hours per resident per day | 2.75 | 2.32 |
| Total nurse staff hours per resident per day on the weekend | 3.85 | 3.42 |
| RN hours per resident per day on the weekend | 0.42 | 0.48 |
| Physical therapist hours per resident per day | 0.08 | 0.07 |
| Total nursing staff turnover | 45.5% | 45.8% |
| Registered nurse turnover | 30.8% | 42.9% |
| Number of administrators who have left the nursing home | 0 | 0.5 |
| Cited for abuse, neglect or exploitation of residents (Care Compare abuse icon) | Yes |
| Number of Fines | 4 |
| Total Amount of Fines in Dollars | $102,910 |
| Number of Payment Denials | 0 |
| Total Number of Penalties | 4 |
| Date | Deficiency | Harm Level | Status |
|---|---|---|---|
| Sep 18, 2025 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. F0600, Freedom from Abuse, Neglect, and Exploitation, Standard inspection, Complaint inspection | Actual harm, isolated | Corrected by Sep 26, 2025 |
| Sep 18, 2025 | Honor the resident's right to organize and participate in resident/family groups in the facility. F0565, Resident Rights, Standard inspection | Potential for harm, pattern | Corrected by Oct 8, 2025 |
| Sep 18, 2025 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, pattern | Corrected by Oct 8, 2025 |
| Sep 18, 2025 | Post nurse staffing information every day. F0732, Nursing and Physician Services, Standard inspection | Minimal harm potential, widespread | No revisit needed |
| 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. F0585, Resident Rights, Standard inspection | Minimal harm potential, pattern | No revisit needed |
| Oct 10, 2024 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. F0600, Freedom from Abuse, Neglect, and Exploitation, Standard inspection | Actual harm, isolated | Corrected by Oct 30, 2024 |
| Oct 10, 2024 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. F0607, Freedom from Abuse, Neglect, and Exploitation, Standard inspection | Potential for harm, isolated | Corrected by Oct 30, 2024 |
| Oct 10, 2024 | Provide special eating equipment and utensils for residents who need them and appropriate assistance. F0810, Nutrition and Dietary, Standard inspection | Potential for harm, isolated | Corrected by Oct 30, 2024 |
| Aug 5, 2024 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. F0600, Freedom from Abuse, Neglect, and Exploitation, Complaint inspection | Immediate jeopardy, pattern | Past non-compliance (already corrected) |
| Aug 5, 2024 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. F0607, Freedom from Abuse, Neglect, and Exploitation, Complaint inspection | Immediate jeopardy, pattern | Past non-compliance (already corrected) |
| Aug 5, 2024 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684, Quality of Life and Care, Complaint inspection | Potential for harm, isolated | Corrected by Aug 25, 2024 |
| Jul 13, 2023 | 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. F0761, Pharmacy Service, Standard inspection | Potential for harm, pattern | Corrected by Aug 15, 2023 |
| Jul 13, 2023 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, pattern | Corrected by Aug 15, 2023 |
| Jul 13, 2023 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. F0550, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Aug 15, 2023 |
| Jul 13, 2023 | 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. F0811, Nutrition and Dietary, Standard inspection | Potential for harm, isolated | Corrected by Aug 15, 2023 |
| Quality Measure | Provider | National Avg. |
|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.62 | 13.87 |
| Percentage of long-stay residents who lose too much weight | 11.24 | 5.19 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.46 | 0.82 |
| Percentage of long-stay residents with a urinary tract infection | 5.67 | 1.59 |
| Percentage of long-stay residents who have depressive symptoms | 2.46 | 12.8 |
| Percentage of long-stay residents who were physically restrained | 0 | 0.13 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.62 | 3.23 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.34 | 93.55 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.91 | 82.04 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.27 | 1.56 |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.53 | 14.07 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 38.85 | 19.52 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.25 | 95.46 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.3 | 79.75 |
| Percentage of long-stay residents with pressure ulcers | 6.31 | 4.62 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.92 | 19.01 |
| Percentage of long-stay residents who received an antipsychotic medication | 15.82 | 15.38 |
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