Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Trinity Grove during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and behavioral disturbances was struck on the face by a nurse aide during care after becoming combative. The incident was witnessed by another aide, who reported the event, and minor marks were observed on the resident's face. The aide involved denied the action, but the deficiency was cited for failure to protect the resident from physical abuse by staff.
Over several months, the facility did not act on or communicate resolutions for concerns repeatedly raised by residents during council meetings, including issues with meal options, call bell response, air conditioning, and staff assistance. Residents reported feeling ignored, and staff interviews confirmed that grievances were not documented or followed up, with no formal process in place to address these concerns.
Staff failed to follow infection control protocols during wound care and did not consistently implement Enhanced Barrier Precautions for residents with wounds and indwelling devices. This included not using barriers during wound care, not wearing required PPE, and missing precaution signage, despite staff having received infection control training.
The facility did not include required census numbers on daily nurse staffing sheets for all neighborhoods and shifts over several days. The temporary scheduler confirmed the omission, and the Administrator was unaware of the incomplete documentation.
A resident's responsible party submitted multiple grievances regarding care and services, including issues with room temperature, meal portions, and laundry. Although staff addressed these concerns verbally or by email, no written grievance summaries were provided as required by facility policy. Staff interviews confirmed a lack of awareness about the need for written responses, and the administrator acknowledged the failure to provide written findings.
A resident with severe cognitive impairment and behavioral disturbances physically assaulted two other residents in separate incidents, grabbing them by the neck and causing distress. Despite interventions and medication management, the facility failed to prevent these altercations, highlighting a deficiency in protecting residents from abuse.
The facility failed to report two resident-to-resident altercations involving residents with dementia and behavioral disturbances to the appropriate authorities, as required by their abuse policy. Despite verbal investigations and medical evaluations, no written reports were completed, and the incidents were not considered abuse by the facility's administration.
A resident with severe cognitive impairment and other medical conditions was not provided with necessary adaptive eating equipment, despite care plan and physician orders. Observations showed the resident was not assisted during meals, leading to no food consumption. Staff interviews revealed a lack of awareness and understanding of the resident's needs, and the facility failed to ensure the provision of adaptive devices.
A nurse aide in a LTC facility was involved in multiple incidents of physical abuse against residents with Alzheimer's and dementia. The aide was observed slapping and popping residents during care, which was witnessed by other staff members but not immediately reported, allowing the abuse to continue.
A nurse aide in an Alzheimer's unit failed to report abuse after witnessing another aide slap a resident. This inaction led to further incidents where the same aide abused additional residents. Despite the facility's policy requiring immediate reporting of abuse, the incidents were not reported promptly, allowing the abusive behavior to continue. The delay in reporting and failure to follow the facility's abuse policy resulted in multiple residents being subjected to physical abuse.
A resident with a history of CVA and on anticoagulant medication experienced an unwitnessed fall in the bathroom. Despite facility policy requiring frequent neurological assessments after such incidents, the responsible nurse did not complete all required checks due to workload and task management issues. The resident had returned from the hospital earlier that day and was left alone in the bathroom for privacy, leading to the fall.
Failure to Protect Resident from Physical Abuse During Care
Penalty
Summary
A severely cognitively impaired resident with Alzheimer's disease, dementia, and behavioral disturbances was involved in an incident where a nurse aide struck her on the left side of her face during care. The resident was known to be agitated and combative during incontinence care, often requiring two staff members and specific interventions such as re-approaching or using diversions to manage her behaviors. On the night of the incident, two nurse aides were providing care when the resident became combative, and after the resident struck one of the aides, that aide responded by slapping the resident with an open hand. The incident was witnessed by the other nurse aide, who reported hearing the accused aide threaten to hit the resident back if struck. The witness observed the slap and described it as a loud clap. The witness was initially afraid to report the abuse in the presence of the accused aide but promptly notified a nurse via text, who then escalated the report to the facility administrator. The resident was assessed following the incident, and small petechiae were noted on her left cheek, but no significant injury or distress was documented. The resident's Power of Attorney also observed marks on the resident's face the following morning and reported the incident to Adult Protective Services. Interviews with staff and the resident's Power of Attorney confirmed the sequence of events, with the accused aide denying the slap and the threat. The resident was unable to provide a coherent account due to her cognitive impairment. The facility's investigation did not substantiate the abuse allegation, citing lack of injury or mental anguish, but the aide involved was terminated. The deficiency centers on the failure to protect the resident from physical abuse by staff during care, despite the resident's known behavioral challenges and the facility's established interventions for managing such behaviors.
Failure to Address and Communicate Resident Council Concerns
Penalty
Summary
The facility failed to act upon and communicate efforts to address concerns reported by the Resident Council over a period of seven out of nine months reviewed. Resident Council meeting agendas and minutes repeatedly documented resident concerns, including issues such as lack of sugar-free desserts, outdated call bell systems, slow call bell response times, broken laundry equipment, malfunctioning air conditioning in resident rooms, insufficient staffing, lack of staff assistance after meals, and limited meal choices. Despite these concerns being voiced and recorded during meetings attended by various department heads, there was no documentation of follow-up actions or communication of resolutions to the Resident Council in subsequent meetings. Interviews with residents revealed ongoing frustration and a perception that their concerns were ignored, as they consistently received responses such as "I'll look into it" without any observable action or feedback. Residents reported feeling that their input did not make a difference, and that management failed to address or resolve the issues raised during the meetings. One resident, who attended all meetings, specifically expressed frustration with the lack of follow-up and resolution to the council's concerns. Staff interviews further confirmed the deficiency. The social worker responsible for recording grievances stated that concerns voiced during Resident Council meetings should have been documented as grievances and forwarded to the appropriate department managers for investigation and resolution. However, a review of the grievance logbook revealed that no grievances had been completed from the Resident Council meetings. The social worker who conducted the meetings admitted to not being trained in overseeing the process or addressing grievances, and the administrator acknowledged the absence of a formal process to address and resolve Resident Council concerns.
Failure to Maintain Infection Control Practices and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during wound care and when implementing Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling medical devices. During wound care for a resident with a Stage III left heel pressure wound, a nurse did not clean the work surface or place a barrier before setting wound care supplies on the resident's dresser, and did not place a barrier under the resident's heel, allowing the wound to come into contact with the floor. The nurse acknowledged not following clean technique and stated she did not think to use a barrier, despite having received infection control training. Additionally, staff did not consistently implement the facility's infection control policy for EBP. One nurse performed a PICC line flush for a resident on EBP while wearing gloves but not a gown, despite an EBP sign being present and PPE supplies available. The nurse was aware of the EBP status but was uncertain about the requirement to wear a gown. Another nurse aide assisted a resident with a Stage III heel wound, also on EBP, without wearing gloves or a gown. There was no EBP sign on the resident's door, and gowns were not available in the room, leading the aide to be unaware of the need for EBP. Interviews with the Infection Control Preventionist Nurse and the Wound Nurse revealed that responsibility for ensuring EBP signage and PPE availability was shared among staff, but oversights occurred, resulting in the absence of required signage and supplies. The administrator confirmed that staff had received annual infection control training, but the observed staff did not follow the facility's infection control measures or EBP policy during the incidents.
Failure to Document Census on Daily Nurse Staffing Sheets
Penalty
Summary
The facility failed to document accurate information on the daily nurse staffing sheets by omitting the census numbers for all four resident neighborhoods across all shifts for four consecutive days. Record review showed that the census fields were left blank on the daily posted nurse staffing information sheets for the first, second, and third shifts on each of these days. During interviews, the temporary scheduler confirmed that she had not been including the facility census on the daily nurse staffing sheets and was unaware of the requirement. The Administrator also stated he was unaware that the census numbers were missing from the posted sheets and acknowledged that the scheduler was new to the position.
Failure to Provide Written Grievance Summaries to Resident's Responsible Party
Penalty
Summary
The facility failed to provide written grievance summaries to a resident's responsible party (RP) after grievances were submitted, as required by facility policy. The policy states that the person filing a concern has the right to receive a written summary detailing the concern, investigative steps, findings, and any corrective actions, with a written response to be provided within three working days. However, review of the grievance log and related documentation revealed that, for at least one grievance regarding a malfunctioning air-conditioning thermostat, the written summary and notification sections were left blank, and there was no evidence that a written summary was provided to the RP. Interviews with facility staff, including the Maintenance Director and Social Worker, confirmed that grievances and concerns reported by the resident's RP were resolved verbally or through email, but no written summaries were given. The Social Worker stated she was unaware of the requirement to provide written grievance summaries and believed verbal communication was sufficient. The Maintenance Director also indicated uncertainty about whether a written summary was ever provided for the air-conditioning grievance. The RP reported submitting multiple grievances, both verbally and by email, and stated she never received a written summary for any of them. The Administrator acknowledged that the RP should have received written grievance summaries for the reported grievances and admitted to not being fully aware of the policy requirement to provide written findings within three days, even if the grievances were resolved verbally. The resident involved was cognitively intact, and the grievances included issues such as small protein serving sizes, delayed mouthwash provision, lack of feeding assistance, laundry issues, and room temperature concerns. Despite these grievances being addressed verbally or through other means, the facility did not fulfill the policy requirement for written communication of grievance outcomes.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by two incidents involving a resident with severe cognitive impairment. The first incident occurred when a resident with dementia and behavioral disturbances grabbed another resident by the neck and choked her in the dining area of the locked dementia unit. This resident had a history of impulsivity, aggression, and paranoia, and was on medications for anxiety and mood disturbances. Despite interventions in place to manage her behaviors, the resident's aggression led to the altercation, causing distress to the victim. A second incident occurred a week later, involving the same aggressive resident who grabbed another resident by the neck and pushed her to the floor. This resident, also with severe cognitive impairment, was known to be irritable and suspicious, and had a history of wandering and taking other residents' belongings. The aggressive resident's actions were reportedly a response to being bumped by the victim's walker, leading to the physical altercation. Both incidents were witnessed by staff, who intervened to separate the residents and ensure their safety. The facility's failure to prevent these incidents highlights a deficiency in protecting residents from abuse. The aggressive resident's medication had been adjusted prior to the incidents, which may have contributed to the escalation in her behavior. Despite staff interventions and monitoring, the facility did not adequately prevent the resident-to-resident altercations, resulting in psychosocial harm to the victims.
Failure to Report Resident-to-Resident Altercations
Penalty
Summary
The facility failed to implement its abuse policy for reporting alleged violations of abuse, neglect, and mistreatment. Specifically, the facility did not report two resident-to-resident altercations to the State Agency, Adult Protective Services, or law enforcement. The facility's policy required immediate reporting of such incidents, but this was not adhered to in the cases involving three residents. In the first incident, a resident with Alzheimer's and dementia was hit and choked by another resident with dementia and bipolar disorder. The altercation was witnessed by a nurse who intervened and separated the residents. Although the Director of Nursing and family members were notified, there was no documentation of a written investigation or report to the appropriate authorities. The second incident involved a resident with Alzheimer's and dementia with behavioral disturbances being pushed down by the same resident involved in the first altercation. Again, the incident was not reported to the required agencies, and no written investigation was conducted. The Director of Nursing and the Administrator were aware of both incidents but did not consider them to be abuse due to the residents' severe dementia and the belief that the actions were reflexive rather than willful. Despite verbal investigations and evaluations by medical professionals, the facility did not complete written reports or notify the necessary authorities as required by their policy.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment for a resident with severe cognitive impairment and other medical conditions, including adult failure to thrive, diabetes, dementia, and protein calorie malnutrition. The resident's care plan and physician orders specified the need for adaptive devices such as a Dycem mat, a right-handed large handle curved spoon, a lightweight non-spill cup with a lid and straw, and a raised edge partitioned plate. Despite these orders, observations during meal times revealed that the resident was not provided with the necessary adaptive equipment and was not assisted by staff, resulting in the resident not consuming her meals. Interviews with staff, including nursing assistants and the unit coordinator, indicated a lack of awareness and understanding of the resident's need for special eating utensils and cups. Nursing Assistant #1 was unaware of any residents requiring special silverware or cups, and Nursing Assistant #2 did not know what a non-spill handled cup was. The unit coordinator stated that nursing staff were responsible for ensuring the provision of adaptive devices, but this was not effectively communicated or executed. The dietary manager confirmed that there was a list of residents requiring adaptive equipment, and the meal tickets included this information. However, the dietary staff's role was limited to plating meals, while nursing staff were expected to provide the adaptive equipment. The administrator acknowledged the expectation that residents should receive assistive devices for eating and drinking, but the facility's failure to ensure this resulted in the deficiency.
Failure to Protect Residents from Abuse by Nurse Aide
Penalty
Summary
The facility failed to protect residents from physical abuse by a nurse aide, identified as NA #2, who was involved in multiple incidents of abuse against residents. On one occasion, NA #2 was observed by NA #1 and NA #4 to have slapped a resident on the nose during care. This resident, who was admitted with Alzheimer's Disease and vascular dementia, was known to be combative during care. Despite the resident's cognitive impairment and aggressive behavior, NA #2's response was to physically strike the resident, which was witnessed by other staff members. In another incident, NA #2 was reported to have slapped another resident on the cheek during a bed bath. This resident, who also had Alzheimer's Disease and dementia, was described as feisty and resistant to care. NA #1 witnessed the slap and noted the resident's shocked reaction. Despite recognizing the inappropriate behavior, NA #1 did not immediately report the incident, which allowed further abuse to occur. A third incident involved NA #2 popping a resident on the mouth twice. This resident, diagnosed with Alzheimer's Disease and psychosis, was being assisted with changing when she attempted to spit on the aides. NA #2's response was to physically reprimand the resident, which was observed by NA #3. These repeated incidents of abuse were not immediately reported by the witnessing aides, contributing to the continuation of the abusive behavior by NA #2.
Failure to Report and Address Abuse in Alzheimer's Unit
Penalty
Summary
The facility failed to identify and report abuse in the Alzheimer's unit when a nurse aide (NA) heard a slapping sound while providing care to a resident. NA #1 heard the sound and questioned NA #2, who admitted to popping the resident on the nose. Despite witnessing this, NA #1 did not report the incident immediately, as she was uncertain if it constituted abuse. This inaction led to further incidents involving other residents, as NA #2 continued to physically abuse residents without being reported or stopped. On a subsequent day, NA #1 and NA #2 were providing care to another resident when NA #1 observed NA #2 slap the resident on the face. NA #1 confronted NA #2 but did not report the incident immediately, leaving the resident alone with NA #2. This failure to report allowed NA #2 to continue her abusive behavior, as evidenced by another incident where NA #3 witnessed NA #2 pop a third resident on the mouth twice. NA #3 also failed to report the incident immediately, contributing to the ongoing risk of abuse to residents. The facility's abuse policy required immediate reporting of suspected abuse to the nursing supervisor, who should then notify the Director of Nursing and the Administrator. However, Nurse #1 delayed reporting the incidents after being informed by NA #1, as she was uncertain if the actions constituted abuse. This delay in reporting and failure to follow the facility's abuse policy resulted in multiple residents being subjected to physical abuse by NA #2, highlighting a significant deficiency in the facility's ability to protect its residents from harm.
Failure to Complete Neurological Assessments After Unwitnessed Fall
Penalty
Summary
The facility failed to complete neurological assessments for a resident who experienced an unwitnessed fall and was on anticoagulant medication. The resident, who had a history of congestive heart failure, cerebral vascular accident (CVA), and hemiplegia, was admitted to the facility with a care plan indicating a potential for falls. On the day of the incident, the resident had returned from the hospital after being treated for congestive heart failure and was alert and oriented. The resident required extensive assistance with mobility and was on Xarelto, an anticoagulant, for CVA. On the day of the fall, the resident was left alone in the bathroom for privacy, as per his preference, after being assisted to the toilet by two nurse aides. The resident fell while reaching for an item, triggering the call light. Nurse #3, who was responsible for the resident, assessed him after the fall and noted a skin tear but did not complete all required neurological assessments due to being busy and not delegating tasks. The facility's policy required neuro checks at specific intervals following an unwitnessed fall, but these were not fully adhered to. Interviews with the nursing staff, including the unit manager and the Director of Nursing, confirmed that the neurological assessments were not completed as per the facility's policy. The Nurse Practitioner and Medical Director emphasized the importance of conducting these assessments to identify any changes in the resident's condition. The failure to complete the neurological assessments was acknowledged by the staff, who were aware of the policy requirements but did not follow through due to workload and task management issues.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wilmington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Care Of Myrtle Grove | 1 mi | ★★★★★ | 7 | 0 |
| Azalea Health & Rehab Center | 3 mi | ★★★★★ | 0 | 0 |
| August Healthcare At Wilmington | 4.3 mi | ★★★★★ | 0 | 0 |
| Peak Resources-wilmington, Inc | 4.4 mi | ★★★★★ | 10 | 1 |
| Cypress Pointe Rehabilitation Center | 5 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.