Trinity Homes: Resident Left in Bed, Soiled - ND
The woman, identified as Resident #4 in inspection records, told investigators she couldn't get out of bed due to her injury. "They just change me," she said during an interview. "I can't get out of bed with this fracture."
On August 13, inspectors observed the resident incontinent of bowel with stool contaminating her wound dressing. Two nurses provided cleanup care and changed both her incontinence product and wound dressing. The resident had a pressure ulcer on her tailbone area and physician orders restricting her to partial weight bearing for two weeks following her femur fracture.
Staff members gave conflicting explanations for why they kept the woman bedridden. A therapy staff member told inspectors they avoided getting her up because she required a mechanical hoyer lift and they worried about worsening her tailbone wound through shearing. The therapist said they had tried standing her at bedside but "she is unable to" and "just isn't there yet."
But an administrative staff nurse provided a different account. She told inspectors the resident "does not get out of bed per her choice" and that staff "only check and change her."
The administrative nurse confirmed facility staff had never attempted alternate toileting methods such as bedpans or bedside commodes.
Trinity Homes' own care plan stated the resident was "frequently incontinent" and required brief changes with assistance from one staff member. The plan called for toileting every two to four hours as needed. Her medical record showed she was cognitively intact and had no physical or verbal behaviors or rejection of care.
The resident's quarterly assessment identified her as dependent on staff for toileting. Physician orders from July 25 included a foley catheter related to wound healing, though inspection records don't specify whether this was in place during the observed incident.
Inspectors found no evidence that facility staff had educated the resident about her current weight bearing status or offered alternative toileting methods. The therapy staff member mentioned they planned to try a sit-to-stand lift with two people to see if she could manage that approach.
The failure to provide appropriate toileting assistance violated federal regulations requiring facilities to provide care for residents who are continent or incontinent. Inspectors determined this created potential for actual harm, noting that inadequate toileting methods can result in unnecessary incontinence, loss of dignity, and avoidable skin issues.
The woman's situation was particularly concerning given her cognitive awareness. Unlike residents with dementia who may not understand their circumstances, she clearly articulated her physical limitations and dependence on staff for basic care.
Her tailbone pressure ulcer added urgency to proper toileting care. Fecal incontinence increases infection risk for open wounds and can significantly delay healing. The contamination of her wound dressing observed by inspectors demonstrated how the facility's approach put her medical recovery at risk.
Trinity Homes had multiple options available that staff acknowledged they never attempted. Bedpans allow toileting without transfers for bedridden patients. Bedside commodes require minimal movement and can accommodate weight-bearing restrictions. Even partial standing with mechanical lift assistance might have been possible with proper planning and staffing.
The therapy staff member's comment that they would "try the sit to stand lift with two of us" suggested the facility had equipment available but hadn't prioritized using it for this resident's toileting needs.
The conflicting staff explanations raised questions about communication and care planning. While the therapist cited medical concerns about worsening her wound, the administrative nurse characterized the situation as the resident's choice, suggesting staff may not have clearly understood her care plan or capabilities.
Federal inspectors classified this as a violation affecting few residents with minimal harm or potential for actual harm. However, for the individual resident involved, the impact was significant - lying in waste while cognitively aware of her situation and dependent on staff who failed to explore basic dignity-preserving alternatives.
The inspection occurred as part of a complaint investigation, though records don't specify what prompted the federal review of Trinity Homes' toileting practices.
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 woman, identified as Resident #4 in inspection records, told investigators she couldn't get out of bed due to her injury.
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.