Trinity Homes: Wheelchair Fall From Missing Foot Pedals - ND
The fall happened on a February evening. The ambulance was called at 9:30 p.m. and arrived fifteen minutes later to take Resident 3 for treatment. The inspection record does not describe the extent of her injuries beyond noting that harm occurred.
The cause was not complicated. The CNA who moved Resident 3 through the facility had simply not put the foot pedals on her wheelchair before transport. Foot pedals keep a seated resident's legs supported and positioned during movement. Without them, a resident's feet can catch the floor or shift the body's weight in ways that tip a person forward and out of the chair.
The investigation was completed on February 18, 2025. Inspectors determined the CNA transported Resident 3 without placing foot pedals on her wheelchair, resulting in a fall, injury, and risk to all residents in the facility.
Trinity Homes told inspectors it had re-educated the CNA immediately after the incident and then retrained all staff on the importance of using foot pedals during transport. The facility also said it completed quality assurance audits to monitor resident safety during transport going forward.
The deficiency was cited under F689, the federal tag covering accidents and the environment of care. Inspectors classified it as past non-compliance, meaning the facility had already taken corrective steps before the August inspection date. The level of harm was recorded as minimal harm or potential for actual harm, a designation that nonetheless reflects that a resident was injured and transported by ambulance.
What the record does not contain is any detail about what happened to Resident 3 after the ambulance left. Whether she was hospitalized, how long she was gone, what injuries she sustained, and whether she returned to Trinity Homes are not addressed in the inspection documents. The report moves quickly from the ambulance's 9:45 p.m. arrival to the facility's corrective actions, leaving the resident herself largely in the background of her own incident.
The inspection was a complaint survey, meaning someone contacted regulators about conditions at the facility before inspectors arrived. The complaint that triggered the visit is not identified in the publicly available deficiency statement.
Trinity Homes is located at 305 8th Ave NE in Minot. The inspection was completed August 14, 2025.
For Resident 3, the night of the fall began with a wheelchair ride and ended with paramedics.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: October 19, 2026 · Our methodology
TRINITY HOMES in MINOT, ND was cited for violations during a health inspection on August 14, 2025.
The fall happened on a February evening.
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.