Trinity Homes: Resident Elopement Unreported - ND
The resident had been admitted to the facility following a fall at home that resulted in "multiple subacute pelvic fractures." Her care plan noted "impaired gait, impaired anticipatory and reactionary balance, and decreased safety awareness" and determined she was "unsafe to return home at this time."
Another resident alerted staff that the woman had left the nursing home to go to a convenience store located two blocks away. A progress note from 4:23 p.m. that day described what staff found: "This writer went to look for resident and found her sitting in her wheelchair by the kerbside and she stated she was tired."
The resident was having difficulty navigating the uneven terrain outside the facility. She told staff "the nursing home looked like a school to her" and explained that she had gone to the convenience store to purchase a candy bar but was unable to get back due to "being tired."
Staff pushed the resident back to her room in the wheelchair. The progress note indicated that the resident's family, weekend manager, social services, and director of nursing were all updated about the incident.
But that's where the facility's response ended.
During interviews with federal inspectors on August 13th, two administrative nurses confirmed that staff failed to complete an incident report following the resident's elopement. The medical record showed no evidence that facility staff reported the incident to the State Health Department, as required by both federal regulations and the facility's own policy.
Trinity Homes' policy on abuse, neglect and exploitation, revised in August 2023, specifically defines neglect as "the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress."
The policy requires the Director of Nursing or Director of Social Services to report alleged neglect "to the Administration and/or their designee and the State Health Department." An initial allegation of abuse reporting form must be completed through the state health department website within 24 hours, and investigation results must be reported within five working days.
None of this happened after the August 2nd elopement.
Federal inspectors determined that the facility's failure to immediately report the incident placed not only the resident who left but other residents at risk for possible neglect and injury. The inspection report noted that allowing a resident with impaired balance and safety awareness to leave undetected represented a significant breakdown in supervision and care.
The resident's medical records, reviewed throughout the inspection period, showed she was cognitively intact according to her admission assessment. This made her elopement particularly concerning, as she was mentally capable of understanding her situation but physically vulnerable due to her recent injuries and documented mobility impairments.
The convenience store the resident attempted to reach was only two blocks from Trinity Homes, but the journey proved too difficult for someone with pelvic fractures using a wheelchair on uneven outdoor terrain. Her statement that she was "tired" and unable to return suggested she may have been stranded at the curb for an unknown period before staff located her.
The fact that another resident noticed and reported the woman's absence raises questions about staff supervision and monitoring procedures. The inspection report provides no details about how long the resident had been gone before she was discovered missing, or what systems should have been in place to prevent the elopement.
Trinity Homes is located on 8th Avenue Northeast in Minot. The facility's failure to follow its own reporting procedures represents a violation of federal requirements for nursing homes receiving Medicare and Medicaid funding.
The August 14th complaint inspection focused specifically on the facility's handling of this elopement incident. Federal regulations require nursing homes to immediately report suspected abuse, neglect, or theft to proper authorities, including state survey agencies, to ensure resident safety and enable appropriate investigation and oversight.
The resident's confusion about the facility's appearance, telling staff that "the nursing home looked like a school to her," may have contributed to her decision to leave. However, the inspection report provides no indication that staff addressed the underlying factors that led to the elopement or implemented additional safeguards to prevent future incidents.
The two administrative nurses who confirmed the reporting failure during their August 13th interviews were identified as nurse #1 and nurse #13 in the inspection documentation. Their acknowledgment that no incident report was completed demonstrates awareness within the facility that proper procedures had not been followed.
Federal inspectors classified this as a violation resulting in "minimal harm or potential for actual harm" affecting "few" residents. However, the failure to report placed both the resident involved and other facility residents at ongoing risk, as state officials were unable to investigate the circumstances or ensure corrective measures were implemented.
The inspection report notes that Trinity Homes must develop an approved plan of correction to continue participating in Medicare and Medicaid programs. The facility has 14 days from receiving the inspection findings to make these documents publicly available.
This elopement incident highlights the vulnerability of nursing home residents with cognitive clarity but physical limitations. The resident understood her desire for a candy bar and attempted to fulfill it independently, but lacked the physical capability to safely complete the journey.
Her exhaustion at the roadside curb, unable to return on her own, illustrates the potential consequences when facilities fail to provide adequate supervision for residents with documented safety awareness deficits and mobility impairments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Trinity Homes from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
TRINITY HOMES in MINOT, ND was cited for violations during a health inspection on August 14, 2025.
The progress note indicated that the resident's family, weekend manager, social services, and director of nursing were all updated about the incident.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.