Trinity Homes

Federal health inspectors cited TRINITY HOMES in MINOT, ND for a deficiency under regulatory tag F-F0578 during a standard health inspection conducted on 2025-08-14.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Scope/Severity Level D: isolated, 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 15 deficiencies cited during this inspection of TRINITY HOMES.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-27.

During an interview on 08/13/25 at 5:20 p.m., two administrative nurses (#1 and #13) confirmed staff failed to complete an incident report following Resident #1's elopement.

The medical record failed to reflect facility staff reported Resident #1's elopement to the State Health Department.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Trinity Homes

305 8th Ave NE Minot, ND 58703

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 08/13/25 at 5:20 p.m., two administrative nurses (#1 and #13) confirmed staff failed to complete an incident report following Resident #1's elopement.

Facility staff failed to complete an incident report after locating Resident #1, including:* Identifying how long Resident #1 was missing from the facility prior to locating her, the weather conditions/appropriateness of her clothing, etc.,* Documenting the results of the physical assessment,* Assessing Resident #1's safety awareness after being told she self-propelled her wheelchair two blocks from the facility, had difficulty navigating the uneven terrain, and thought the facility looked like a school, * re-educating Resident #1's on the procedure for leaving the facility, i.e.: sign-out book.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Trinity Homes

305 8th Ave NE Minot, ND 58703

SUMMARY STATEMENT OF DEFICIENCIES

Based on record review, review of professional reference, review of facility policy, and staff interview, the facility failed to follow professional standards of practice regarding physician's orders for 1 of 1 sampled resident (Resident #30) with orders for a physical therapy/occupational therapy (PT/OT) evaluation.

Failure to transcribe and obtain a PT/OT evaluation placed Resident #30 at risk for delayed treatment.

Findings include:Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, Nurses are expected to analyze procedures . ordered by the physician or primary care provider. If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out.

Review of the facility policy titled Provider Orders occurred on 08/14/25.

This policy, dated September 2022, stated, . PHYSICIANS ORDERS . all orders must be on the chart of the resident .

Observed, sign, date and time, in red, beneath the providers written orders on Provider order sheets. enter order into the electronic health record.

Review of Resident #30's medical record occurred on all days of survey.

Diagnoses included arthritis, weakness, and difficulty walking. A provider's progress note, dated 05/07/25, stated, . chronic ambulatory dysfunction . wheelchair bound . currently a Hoyer [mechanical lift] transfer . An undated physician's order, scanned into the medical record, stated, PT/OT evaluate transfer/maneuver electric wheelchair safely.

The physician's order lacked evidence facility staff acknowledged the order.

The record lacked documentation of a PT/OT evaluation for electric wheelchair use.

Observations on all days of survey showed an electric wheelchair Resident #30's room.

During an interview on 08/11/25 3:14 p.m., Resident #30 identified she would like to receive some therapy and to use her electric wheelchair.

During an interview on 08/13/25 at 8:15 a.m., a therapy manager (#6) confirmed therapy staff had not received notification of an evaluation order for Resident #30.

During an interview on 08/13/25 at 11:00 a.m., an administrative nurse (#7) confirmed the provider wrote the order, failed to date it, and facility staff failed to carry out the order.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Trinity Homes

305 8th Ave NE Minot, ND 58703

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation, record review, and resident and staff interview, the facility failed to ensure residents received the necessary services to maintain personal hygiene for 2 of 23 sampled residents (Resident #4 and #104) dependent on staff for personal hygiene.

Failure to provide assistance with hair, oral, and nail care may result in poor hygiene and decreased self-esteem and quality of life.

Findings include: The facility failed to provide a policy for activities of daily living. -Observation on 08/11/25 at 4:29 p.m. showed Resident #4's hair uncombed.

The resident stated, I only get my hair combed about once a week and teeth brushed occasionally.

Review of Resident #4's medical record occurred on all days of survey.

The care plan stated, . [Resident #4's name] is not able to perform her own ADL's [activities of daily living] related to weakness and right femur fracture.

Grooming/Personal Hygiene: staff assistance of one for assistance at bedside.

Encourage [Resident #4's name] to . comb hair Oral hygiene: partials/own teeth.

Oral cares bid [twice a day] .

Encourage [Resident #4's name] to brush own teeth after set up .

Review of Resident #4's personal hygiene task record from 07/14/25 to 08/09/25 identified the facility staff failed to assist the resident with personal hygiene (combing hair and brushing teeth) five times. -Observation on 08/11/2025 at 2:56 p.m. showed Resident #104's great toenails to both feet approximately three-fourths inches in length with jagged edges.

Review of Resident #104's medical record occurred on all days of survey.

The care plan stated, .

Hand and foot nail care to be done by CNA [certified nurse aid] .

During an interview on 08/14/25 at 1:17 p.m. an administrative staff nurse (#1) stated he expected the CNAs to assist dependent residents with all ADLs including combing hair and brushing teeth twice a day.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Trinity Homes

305 8th Ave NE Minot, ND 58703

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services for 1 of 6 sampled resident (Resident #6) observed during dressing changes.

Failure to complete dressing changes as physician ordered placed the resident at risk for delayed wound healing.

Findings include:

Review of the facility policy titled Skin Management occurred on 08/14/25.

This policy, dated December 2022, stated, .

Wound Care Guidelines .

Floor nurse will observe wound daily .

Wound care dressings will be dated and initialed.

Floor nurse will document observed wounds . in the resident's EHR [electronic health record].Review of Resident #6's medical record occurred on all days of survey. A physician's order, dated 11/27/24, identified a dressing change to the resident's right leg once a day.

Observation on 08/12/25 at 9:30 a.m. showed a nurse (#12) removed a dressing dated 08/10/25 from Resident #6's right leg.

The nurse (#12) stated, I don't know what happened.

They must have forgot to change the dressing yesterday.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Trinity Homes

305 8th Ave NE Minot, ND 58703

SUMMARY STATEMENT OF DEFICIENCIES

Review of the wound care documentation, dated 08/07/25, showed a stage IV (full thickness tissue loss, exposing underlying bone, muscle or tendon) pressure ulcer to Resident #4's sacral region and measured 11 centimeters (cm) by 10.5 cm width and 2 cm undermining.Resident #4's repositioning record, dated July 15 to August 13, 2025, identified the following:- Not repositioned: 1 day zero times- Repositioned once: 6 days - Repositioned twice: 14 days - Repositioned three times: 7 days - Repositioned four times: 1 day

During an interview on 08/14/25 at 9:49 a.m., an administrative staff member (#7) confirmed Resident #4's turning and repositioning task failed to show staff repositioned the resident every 2-3 hours.

The administrative staff member stated she expected facility staff to reposition the resident every two to three hours.

During an interview on 08/14/25 at 1:17 p.m., an administrative staff member (#1) stated staff should reposition Resident #4 every 2-3 hours.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Trinity Homes

305 8th Ave NE Minot, ND 58703

SUMMARY STATEMENT OF DEFICIENCIES

Based on the following information, non-compliance at F-F689 is considered past non-compliance.

The facility implemented corrective actions to ensure the deficient practice does not recur by:* Completing an investigation on 02/18/25, including an interview with the CNA who transported Resident #3,* Determining the CNA transported Resident #3 without placing foot pedals on her wheelchair, resulting in a fall from her wheelchair, injury, and placed all residents at risk for falls with/without injury.* Immediately re-educating the CNA following the incident and re-educating all staff on the importance of utilizing foot pedals during resident transport.* Completing quality assurance audits to ensure resident safety during transport.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Trinity Homes

305 8th Ave NE Minot, ND 58703

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 08/11/25 at 4:41 p.m., Resident #4 stated she wears an incontinent product and They just change me. I can't get out of bed with this fracture.

During an interview on 08/14/25 at 8:00 a.m., a therapy staff member (#6), stated, We do not get her (Resident #4) out of bed because she requires the hoyer lift [mechanical lift] and we do not want to risk her coccyx wound getting worse from shearing.

The staff member (#6) also stated, We have tried to stand her (Resident #4) at bedside and she is unable to.

She just isn't there yet. We will try the sit to stand lift with two of us and see if she can do that.

During an interview on 08/14/25 at 8:08 a.m., an administrative staff nurse (#7) stated Resident #4 does not get out of bed per her choice, and staff only check and change her.

The administrative staff nurse confirmed facility staff have not attempted alternate toileting methods, such as the bed pan, bedside commode, etc.

The medical record lacked evidence the facility staff educated Resident #4 on her current weight bearing status and offered alternate toileting methods, which may have resulted in avoidable incontinence, decreased dignity, and risk of further skin breakdown.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Trinity Homes

305 8th Ave NE Minot, ND 58703

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 08/14/25 at 1:17 p.m., an administrative staff member (#1) stated he expected staff to offer dependent residents water with cares.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Trinity Homes

305 8th Ave NE Minot, ND 58703

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 9 residents (Resident #65 and #96) observed during medication administration.

Two medication errors occurred during staff administration of 27 medications, resulting in a 7% error rate.

Failure to follow physicians' orders and administer medications in the correct dose and at the correct time may result in residents receiving an ineffective and/or inaccurate dose and experiencing adverse reactions.Findings include:

Review of the facility's policy titled Medication Administration and Crushing Medications occurred on 8/14/25.

This policy, approved October 2024, stated, . OBJECTIVE: 1. To administer medications as ordered by a provider .

Provider's Order must be obtained and observed for all medications.

Read the medication label and compare with the HER [sic] [electronic health record (EHR)] ensuring the five rights: a.

Right drug .

Right dose .

Right route .

Right time .

Right resident.

Review of Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th ed., Pearson Education Inc., New Jersey, page 835, stated, Process of Administering Medications .

Medications prescribed more frequently than daily, but no more frequently than every 4 hours . [Administer] Within 1 hour before or after the scheduled time. -Observation on 08/11/25 at 4:32 p.m. showed a nurse (#15) administered one drop of Refresh eye drops to both of Resident #65's eyes.

The Refresh label stated two drops left eye twice daily.

After returning to the medication cart, the nurse confirmed the order stated two drops to left eye twice daily.

Review of Resident #65's physician's order verified two drops to left eye until redness resolves then discontinue. -Review of Resident #96's medical record occurred on all days of survey and showed a physician's order for Cefepime 2 Gram (an antibiotic medication) every 12 hours for 14 days for bacteremia/sepsis.

Review of Resident #96's electronic medication administration record (EMAR) showed scheduled administration times for the Cefepime at 9:00 a.m. and 9:00 p.m.

Observation on 08/12/25 at 10:49 a.m. showed a nurse (#2) administered the Cefepime.

This exceeded the one-hour after the scheduled time of 9:00 a.m. by 49 minutes.

During an interview on 08/13/25 at 2:00 p.m., an administrative nurse (#1) stated he expected staff to administer medication within an hour prior to the scheduled time to an hour after the scheduled time.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Trinity Homes

305 8th Ave NE Minot, ND 58703

SUMMARY STATEMENT OF DEFICIENCIES

Observation on 08/14/25 at 8:36 a.m. showed a nurse (#11) removed Resident #12's Novolog insulin pen from the medication cart.

The label on the insulin pen and on a box with additional insulin pens identified 20 units before meals and at bedtime.

The current physician's order identified 25 units before meals and before bedtime.

When asked, a nurse manager (#3) and the nurse (#11) stated Resident #12 received a recent order change and both confirmed the label on the insulin pen and box failed to reflect the change. -

Review of the facility policy titled Supplies - Outdated - [NAME] Homes occurred on 08/14/25.

This policy, revised January 2023, stated, OUTDATED SUPPLIES 1.

All supplies will be checked once a month. 2.

Supplies that are outdated will be discarded.

Observations of medication storage showed the following: -08/12/25 at 5:15 p.m., a tube of Muscle Rub topical cream with an expiration date of 08/2024 located in the medication cart on 3 North East. -08/14/25 at 11:38 a.m., one box of Acetaminophen 650 milligrams (mg) suppositories with an expiration date of 12/2024, and one box of Bisacodyl 10mg suppositories with an expiration date of 07/2025 located in the medication refrigerator on 3 South. -08/14/25 at 11:45 a.m., one bottle of aspirin 325mg with an expiration date of 05/2025 located in the medication cupboard on 3 North East.

During an interview on 08/14/25 at 1:50 p.m., supervisory staff members (#1, #10, and #13) agreed staff should remove expired medications from the storage areas.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Trinity Homes

305 8th Ave NE Minot, ND 58703

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation, review of facility policy, and staff interview, the facility failed to discard expired food and supplements in 2 of 6 food storage areas (Main kitchen and 4 North kitchenette) observed.

Failure to discard expired food/supplements has the potential to affect the quality of the item served to residents related to safety and nutrition.Findings include:

Review of the facility policy titled Dietary Policy/Procedure occurred on 08/14/25.

This undated policy stated, . PURPOSE: To assure that foods served are wholesome and not out dated.

All foods rotated by date and stored properly.

Observations showed the following: -08/11/25 at 1:15 p.m., main kitchen: the large walk-in freezer contained a partially uncovered pan of corned beef dated March 2024. -08/13/25 (morning), 4 North kitchenette: an opened container of Prosource (dietary supplement) expired October 2024. -08/13/25 at 3:00 p.m., main kitchen: approximately 42 boxed containers of Ensure Clear (dietary supplement) with expiration dates from April 2025 through August 1, 2025.

During an interview on 08/14/25 at 9:00 a.m., a dietary supervisor (#16) verified the facility lacked a consistent process to monitor for expired foods/supplements, and staff should discard the expired food/supplements.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Trinity Homes

305 8th Ave NE Minot, ND 58703

SUMMARY STATEMENT OF DEFICIENCIES

Federal health inspectors cited TRINITY HOMES in MINOT, ND for a deficiency under regulatory tag F-F0880 during a complaint investigation conducted on 2025-08-14.

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 15 deficiencies cited during this inspection of TRINITY HOMES.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-27.