Trinity Homes: Wound Care Neglect Found - ND
Federal inspectors observed nurse #12 removing a dressing dated August 10th from Resident #6's right leg on August 12th at 9:30 a.m. The physician had ordered daily dressing changes for the resident's right leg wound since November 27th, 2024.
"I don't know what happened," the nurse told inspectors. "They must have forgot to change the dressing yesterday."
The missed care placed the resident at risk for delayed wound healing, according to the August 14th inspection report from the Centers for Medicare and Medicaid Services.
Trinity Homes' own wound care policy, dated December 2022, requires floor nurses to observe wounds daily and ensure wound care dressings are dated and initialed. The policy also mandates that nurses document observed wounds in residents' electronic health records.
The facility's policy states that wound care guidelines include daily wound observation by floor nurses and proper documentation of wound care dressings with dates and initials.
Federal inspectors reviewed Resident #6's medical records throughout their survey period. The physician's order from November 27th, 2024, clearly specified once-daily dressing changes for the resident's right leg wound.
The violation represents a failure to provide necessary care and services according to physician orders. Inspectors classified the incident as causing minimal harm or potential for actual harm to the resident.
This type of oversight in wound care can have serious consequences for nursing home residents. Wounds that don't receive proper attention according to medical orders can become infected, heal more slowly, or develop complications that require more intensive treatment.
The inspection found that Trinity Homes failed to follow its own established protocols for wound management. The facility's December 2022 skin management policy explicitly requires nurses to complete daily wound observations and ensure dressings are properly dated and initialed by staff.
When the nurse discovered the outdated dressing during the inspection, it highlighted a breakdown in the facility's wound care system. The dressing should have been changed on August 11th according to the physician's daily change order.
The fact that staff "forgot" to change the dressing, as the nurse explained to inspectors, suggests potential gaps in the facility's care coordination and oversight systems. Daily wound care is a fundamental nursing responsibility, particularly when specifically ordered by a physician.
Trinity Homes operates at 305 8th Avenue NE in Minot. The facility was inspected following a complaint, though the inspection report doesn't specify the nature of the original complaint that triggered the federal review.
The missed wound care occurred despite clear documentation requirements in the resident's electronic health record system. Proper wound documentation helps ensure continuity of care and allows staff to track healing progress and identify potential problems.
Federal inspectors noted that few residents were affected by this particular deficiency, focusing their finding on Resident #6's case. However, the violation raises questions about whether similar oversights might be occurring with other residents' wound care.
The August 12th discovery came during routine inspection observations. Inspectors were present when nurse #12 removed the two-day-old dressing, allowing them to document the violation in real time.
Wound care represents a critical aspect of nursing home care, particularly for elderly residents who may have compromised healing abilities. Daily dressing changes, when ordered by physicians, are designed to keep wounds clean, monitor healing progress, and prevent infections.
The resident's physician had determined that daily dressing changes were medically necessary for the right leg wound. This type of order typically indicates the wound requires close monitoring and regular care to heal properly.
Trinity Homes must now develop a plan of correction to address the wound care deficiency. The facility will need to demonstrate how it will prevent similar oversights and ensure physician-ordered wound care is completed as prescribed.
The inspection report doesn't indicate how long the pattern of missed dressing changes might have continued without the federal inspector's presence. The nurse's surprise at finding the outdated dressing suggests this wasn't a known ongoing issue, but rather a failure in the facility's daily care routine.
For Resident #6, the delayed wound care meant going at least 48 hours without the medical attention their physician deemed necessary for proper healing.
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 21, 2026 · Our methodology
TRINITY HOMES in MINOT, ND was cited for neglect violations during a health inspection on August 14, 2025.
Federal inspectors observed nurse #12 removing a dressing dated August 10th from Resident #6's right leg on August 12th at 9:30 a.m.
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.