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Complaint Investigation

Trinity Grove

Inspection Date: September 18, 2025
Total Violations 5
Facility ID 345554
Location Wilmington, NC
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Inspection Findings

F-Tag F0565

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Trinity Grove in Wilmington, NC for a deficiency under regulatory tag F-F0565 during a standard health inspection conducted on 2025-09-18.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to organize and participate in resident/family groups in the facility.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Trinity Grove.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-08.

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F-Tag F0585

Resident Rights Deficiencies
Harm Level: Potential for Minimal Harm

Federal health inspectors cited Trinity Grove in Wilmington, NC for a deficiency under regulatory tag F-F0585 during a standard health inspection conducted on 2025-09-18.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: 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.

Scope/Severity Level B: isolated, no actual harm with potential for minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Trinity Grove.

Correction Status: No revisit needed.

The facility reported correction as of 2025-10-08.

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F-Tag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Actual Harm

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

her he had had interviewed both of the nurse aides involved. He reported to her that he had escorted the accused nurse aide out of the building and suspended her. The POA stated Resident #65 had been at the facility for 6 years and that this was the first time anything like this had happened to her. She noted she had not visited Resident #65 on Friday (08/29/25) but had seen her the day before (Thursday) and the marks on her face were new.An observation of Resident #65 was made on entry (09/15/25) at lunchtime at 12:05 PM and again on 09/16/25 at 12:30 PM. No marks were visible on the left side of Resident #65's face. An attempt was made to interview Resident #65 on 09/17/25 at 3:05 PM, but Resident #65 was not able to understand the conversation. An interview was conducted with Nurse Practitioner #1 on 09/18/25 at 1:33 PM by telephone. She stated when she had assessed Resident #65 on 09/02/25 she had not found any frank marks or bruising on the resident's face. Nurse Practitioner #1 explained although she did observe 3 petechia dots on the resident's left facial cheek, she wouldn't call those marks a bruise. She noted the petechia could have just been due to the aging process and changes in the resident's skin. She stated Resident #65 was at baseline and was not able to tell her if anyone had hit her.An interview was conducted with the Administrator on 09/18/25 at 10:30 AM. He stated that he did not substantiate this allegation of abuse because when he talked to the local law enforcement officer who had responded to the incident, the information the office told him regarding staff interviews varied from the staff interviews that he had conducted himself. The Administrator explained he did not have a copy of the law enforcement report because when he had asked the officer for a copy of the report he was told the report had not been written yet and that the investigation was still open. The Administrator provided a Plan of Correction with an alleged completion date of 09/04/25, but it was not accepted because the plan did not include monitoring of staff to resident interactions or of care being provided.

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F-Tag F0732

Nursing and Physician Services Deficiencies
Harm Level: Potential for Minimal Harm

Federal health inspectors cited Trinity Grove in Wilmington, NC for a deficiency under regulatory tag F-F0732 during a standard health inspection conducted on 2025-09-18.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Post nurse staffing information every day.

Scope/Severity Level C: pattern, no actual harm with potential for minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Trinity Grove.

Correction Status: No revisit needed.

The facility reported correction as of 2025-10-08.

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F-Tag F0880

Infection Control Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Trinity Grove in Wilmington, NC for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-09-18.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Trinity Grove.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-08.

📋 Inspection Summary

Trinity Grove in Wilmington, NC inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Wilmington, NC, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Trinity Grove or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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