Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Trinity Homes during CMS and state inspections, most recent first.
A resident was injured during van transport when the shoulder strap seatbelt was not secured due to distraction during conversation with the transporter. The resident fell from the wheelchair after the van stopped abruptly, resulting in a leg fracture and subsequent hospitalization. Although van drivers had completed required training and other residents reported feeling safe, the necessary supervision and use of safety devices were not provided in this incident.
Failure to ensure participation in person-centered care planning was identified for two residents. One resident stated being unaware of the care planning conferences and never attending them, and the record lacked evidence of notice or staff interview about care concerns. Another resident's representative reported not receiving notification of the care planning conference, and the record lacked evidence that the representative was informed.
Code status not updated to match resident wishes. A resident returned from the hospital with a DNR form signed by the POA, but the EHR and physician order still showed full code until the next day. Management and admin staff confirmed the code status change had not been entered promptly, leaving the resident’s record out of sync with the current signed decision.
Two residents with severe cognitive impairment engaged in non-consensual sexual contact when one was found touching the other's breasts in a shared room. Both had histories of behavioral issues and required close monitoring, but staff did not prevent the incident, resulting in a failure to protect them from abuse as defined by facility policy.
A resident with a history of aggressive and inappropriate behaviors, including verbal, physical, and sexual misconduct, was not effectively managed by the facility, leading to an unsafe environment for other residents. The resident's care plan failed to address these behaviors, and staff did not adequately monitor or report incidents, resulting in ongoing abuse and fear among other residents.
A resident with dementia and aggressive behaviors was not provided adequate care and services, leading to verbal, physical, and sexual abuse towards other residents. The facility lacked a specific dementia care policy and failed to identify situational stressors or implement effective behavior management interventions. Staff did not consistently report or address the resident's behaviors, resulting in fear and anxiety among other residents.
A resident with multiple health conditions developed a Stage 2 pressure ulcer on the left heel due to the facility's failure to implement ordered interventions and ensure adequate monitoring. The care plan did not include the ulcer, and staff did not consistently apply preventative devices or dressings. Observations showed the resident often without prescribed Prevalon boots and proper wound care, leading to an avoidable facility-acquired pressure ulcer.
A facility failed to provide adequate supervision and safe transfer methods, resulting in injuries to three residents. One resident required surgical intervention after a CNA improperly transferred them from a shower, causing a hematoma and cellulitis. Two other residents were at risk due to improper use of a sit-to-stand lift and unsafe transportation methods. The facility did not monitor or re-evaluate the suitability of transfer methods, leading to discomfort and potential harm.
The facility failed to update care plans for several residents, impacting the management of conditions such as lymphedema, aspiration risk, surgical wounds, pressure ulcers, and dehydration. This lack of updates limited staff's ability to ensure continuity of care.
The facility's main kitchen walk-in freezer had unsanitary conditions with frost buildup on shelves and packages, and fans covered in frost. One fan had a drip tray with icicles, while others did not, leading to ice buildup on food items. A dietary assistant noted that parts were ordered for repair, but the issue persisted during a follow-up observation.
The facility failed to follow infection control standards, including hand hygiene and PPE use, for several residents. Staff did not perform hand hygiene between glove changes and failed to apply enhanced barrier precautions (EBP) for residents with indwelling devices or draining wounds. Observations revealed non-compliance with infection control policies, risking the spread of infections.
The facility failed to adhere to professional standards by not obtaining physician orders for treatments and not notifying physicians of treatment refusals for two residents. One resident refused protective liners under compression wraps, risking skin tears, while another had a dressing change without a physician's order for a leg hematoma.
A facility failed to restore oral eating skills for a resident with a gastrostomy tube and severe dysphagia. Despite being on an NPO diet, the resident was allowed pleasure feedings, but the facility did not clarify conflicting oral intake orders or update the speech therapy evaluation for two years. The resident had a history of aspiration, and staff confirmed supervision during snacks, yet the facility did not address the conflicting orders or reassess swallowing capabilities.
A facility failed to maintain proper infection control practices for a resident with a tracheostomy. The resident's oxygen humidifier and tubing were found on the floor, and a CNA connected the tubing to the resident's tracheostomy collar mask despite acknowledging the issue. The resident had a history of respiratory issues and required specific oxygen therapy, with expectations for supplies to be stored off the floor.
The facility failed to conduct timely Abnormal Involuntary Movement Scale (AIMS) assessments for residents on antipsychotic medications. A resident on risperidone lacked six-monthly AIMS assessments, another on olanzapine had a delayed initial assessment, and a third on chlorpromazine had no initial AIMS assessment. An administrative nurse confirmed the absence of a policy for AIMS assessments, expecting staff to perform them at medication initiation and every six months.
A resident with severely impaired cognition fell from a mechanical lift, sustaining serious injuries. The incident was reported to the SSA approximately 19 hours later, exceeding the required 2-hour reporting timeframe, thus failing to comply with regulations.
A resident with severe cognitive impairment fell from a mechanical lift, sustaining facial lacerations. The facility failed to document the fall and perform required neurological assessments in a timely manner, as per policy. Staff interviews confirmed the lack of documentation and incomplete assessments.
Failure to Secure Resident with Seatbelt During Van Transport Results in Injury
Penalty
Summary
A deficiency occurred when a resident was being transported back to the facility in a van and was not properly secured with the shoulder strap seatbelt. The transporter and the resident were engaged in conversation while the transporter was securing the wheelchair to the floor of the van, resulting in both parties forgetting to secure the seatbelt that crosses over the resident. During the trip, the van had to stop abruptly at a stoplight, causing the resident, who was leaning forward in the wheelchair, to fall out. The resident sustained an abrasion, bruising, swelling to the right knee, and complained of shooting pain from the knee to the hip, which led to a hospital admission and surgery for a fractured femur. Review of the facility's records and interviews confirmed that the transporter did not realize the shoulder strap was not secured until after the resident fell. Documentation showed that all van drivers had completed competency verification and training prior to becoming transporters, and interviews with other residents indicated that they typically felt safe and were secured with the crossover belt during transport. However, in this instance, the required supervision and use of assistance devices to prevent accidents were not provided, directly resulting in the resident's injury.
Failure to Notify Residents and Representatives of Care Planning Conferences
Penalty
Summary
Failure to ensure residents could participate in the development and implementation of their person-centered plan of care was identified for 2 of 31 sampled residents. Facility policy stated that a written plan of care is to be developed and maintained for each resident in coordination with all services and individuals involved in the resident's care, and that family members, support persons with the resident's permission, and/or the resident will be invited to attend the care planning conference. For one resident, the medical record showed care planning conferences were held, but the resident stated during interview that he or she was unaware of the conferences and never attended them. The record lacked evidence that the resident received notice of the conferences or that staff interviewed the resident about care concerns or needs. For another resident, the record showed a care planning conference was held, but the resident's personal representative stated she did not receive notification from the facility, and the record lacked evidence that the representative was notified.
Code Status Not Updated to Match Resident Wishes
Penalty
Summary
The facility failed to ensure Resident #84’s right to request, refuse, and/or discontinue treatment was reflected in the medical record when the resident’s code status changed from full code to DNR after return from the hospital. Review of the facility’s Code Status policy showed nursing services were to verify provider orders and/or the resident’s decision so the code order in the EHR matched what the resident or resident representative had signed. The resident’s record contained a physician order dated 02/18/25 for full code, and the EHR identification ribbon also showed full code. On 08/12/25, a management staff member presented a code status form signed by the resident’s POA indicating DNR and stated the resident returned from the hospital that day and the code status changed. The record showed facility staff did not update the EHR from full code to DNR until 08/13/25 at 8:30 a.m., and an administrative staff member confirmed the code status had not been changed when interviewed the morning of 08/13/25.
Failure to Prevent Non-Consensual Sexual Contact Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect two residents with impaired cognition from sexual abuse, as both were involved in an incident of non-consensual sexual contact. A certified nurse aide discovered one resident lying on another resident's bed with her shirt pulled up while the other resident was touching her breasts. Both residents were known to have severe cognitive impairment due to Alzheimer's disease and dementia, and neither had the capacity to consent to sexual activity. The incident was observed by staff, and both residents were immediately separated. Review of the medical records revealed that one resident had a history of unpredictable behaviors, wandering, removing her clothes, and being found in other residents' rooms. The other resident had a documented history of making inappropriate comments to female staff, occasional episodes of cursing, rejection of care, and a prior episode of touching a female resident's breasts. Both residents were on a secured unit and had very poor short-term memory, with care plans indicating the need for monitoring and interventions to prevent inappropriate interactions. Despite these known risks and behavioral histories, the facility did not prevent the incident of non-consensual sexual contact between the two residents. Staff interviews confirmed that neither resident showed distress at the time, and both lacked the cognitive ability to remember or consent to the event. The failure to ensure adequate supervision and monitoring led to the occurrence of sexual abuse as defined by the facility's policy.
Failure to Protect Residents from Abuse by Aggressive Resident
Penalty
Summary
The facility failed to protect residents from abuse by a resident with a history of verbal, physical, and sexual behaviors. The report details multiple incidents involving this resident, who exhibited aggressive and inappropriate behaviors towards other residents in the memory care unit. These behaviors included kicking, blocking, and verbally abusing other residents, as well as sexually inappropriate actions such as grabbing female residents' breasts. Despite these repeated incidents, the facility did not effectively assess, care plan, or implement a process to manage the resident's behaviors, resulting in an unsafe environment for other residents. The resident in question had diagnoses of anxiety, dementia, mood disturbance, and psychotic disturbance, with severe cognitive deficits and behaviors noted in their medical record. The facility's progress notes documented numerous instances of the resident's aggressive and inappropriate actions over a period of time, including physical altercations, verbal abuse, and sexual misconduct. These incidents caused fear and anxiety among other residents, particularly female residents who expressed being afraid to go near the resident. The facility's care plan for the resident was inadequate, failing to identify situational stressors or address the resident's sexually abusive behaviors. Interviews with staff revealed that there was a lack of communication and monitoring of the resident's behaviors, with some incidents not being reported to administrative staff. The facility's failure to assess and monitor patterns and trends of the resident's behaviors contributed to the ongoing abuse and infringement upon the rights of other residents to be free from abuse.
Inadequate Dementia Care and Behavior Management
Penalty
Summary
The facility failed to provide adequate dementia care and services for a resident diagnosed with dementia and exhibiting verbal, physical, and sexual abusive behaviors. The facility did not have a specific policy on dementia care, and the existing care plan for the resident did not adequately address the situational stressors or the sexually abusive behaviors towards female residents. The care plan included interventions such as allowing the resident time to calm down, distracting him with food or activities, and removing him from areas when agitated, but these measures were insufficient in managing the resident's behaviors. The resident's medical record indicated multiple incidents of aggressive and abusive behavior towards other residents, including verbal abuse, physical altercations, and inappropriate sexual conduct. Despite these documented behaviors, the facility staff failed to identify and monitor patterns or trends in the resident's behavior, which could have helped in recognizing unmet needs and preventing triggers that led to these behaviors. The facility also did not consistently implement meaningful activities that could have potentially managed the resident's behaviors more effectively. Interviews with facility staff revealed a lack of communication and reporting regarding the resident's behaviors, particularly towards female residents. The facility did not develop an effective behavior management program or evaluate and modify interventions as needed. This lack of action resulted in the resident infringing upon the rights of other residents, causing fear and anxiety among them due to the resident's abusive behaviors.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent the development of a pressure ulcer for a resident with existing pressure ulcers. The resident, who had diagnoses including end-stage renal disease, diabetes mellitus, and peripheral vascular disease, developed a Stage 2 pressure ulcer on the left heel. The care plan did not include this ulcer, and the facility did not implement interventions as ordered, such as the use of Prevalon boots, which the resident intermittently refused to wear. Staff failed to document these refusals and did not consistently apply preventative devices or dressings to the wound. Observations revealed that the resident was often without the prescribed Prevalon boots, with her feet directly on the floor or mattress, and without proper dressings on the left heel. Despite the resident's high risk for complications, as noted in podiatry progress notes, the facility did not ensure regular assessments of the wound's size and condition. The resident's care plan was not updated to reflect the necessary interventions for the left heel pressure ulcer, and staff did not follow infection control measures during wound care. The facility's inaction and lack of adherence to the care plan resulted in an avoidable facility-acquired pressure ulcer. The failure to monitor and assess the resident's condition adequately, along with the lack of documentation of care refusals, contributed to the development and progression of the pressure ulcer. The facility did not provide the necessary interventions to aid in the healing of the wound, which could lead to further complications for the resident.
Inadequate Supervision and Unsafe Transfers Lead to Resident Injuries
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who required surgical intervention for an injury. The incident occurred when a certified nurse aide (CNA) attempted to transfer the resident from the shower using a bariatric chair in a small area, resulting in the resident's leg hitting the shower wall. This caused severe pain, a hematoma, cellulitis, and increased anxiety and depression for the resident. The resident's medical history included atrial fibrillation, anemia, long-term use of anticoagulants, and cellulitis of the left lower limb. The resident experienced three hospitalizations and required surgical debridement and a wound vacuum-assisted closure device. The facility also failed to ensure safe transfers for two other residents using a sit-to-stand mechanical lift. One resident, who had Alzheimer's disease and muscle weakness, was observed being transferred with the lift in a manner that caused discomfort and potential harm. The resident's arms were raised to a horizontal position during the transfer, and the safety strap was not properly adjusted, causing the resident to sag against the harness. The staff did not monitor or re-evaluate the suitability of the lift for the resident's needs, despite the resident's apparent decline in ability to bear weight. Another resident, who was at risk for bleeding and bruising due to blood thinner medication, fell out of a power wheelchair while being transported in a van with a ramp instead of a lift. The resident sustained bruises on the right arm and legs. The facility did not complete an incident report or investigation following the fall, and the transport company was not informed of the resident's transfer requirements and safety needs. The facility's failure to evaluate and ensure safe transfer methods placed the resident at risk for injury.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for six of the 25 sampled residents, which limited the staff's ability to communicate needs and ensure continuity of care. For Resident #29, the care plan did not include a problem, goals, or interventions to manage lymphedema, despite a physician's order for physical therapy evaluation and treatment. An administrative staff member mentioned that the facility typically does not address edema due to frequent changes in orders. Resident #33's care plan lacked an intervention for supervision during oral feedings to prevent aspiration, even though the resident was at high risk of aspiration and had a history of failed swallowing exams. Similarly, Resident #66's care plan did not address surgical incisions on the abdomen and right knee, which were documented in the resident's medical record. Resident #68's care plan failed to address a stage III decubitus ulcer on the left heel, as noted in a podiatry consult and wound observation forms. Additionally, Resident #88's care plan did not reflect the use of an Unna boot on the right leg and a Coflex wrap on the left leg, despite a physician's order for these treatments. Resident #317's care plan was missing interventions for the use of a diuretic and measures to prevent dehydration, even though the resident had a history of heart failure, chronic kidney disease, and a recent hospital discharge note indicating acute kidney injury and dehydration. These omissions in care plans indicate a failure to update and maintain accurate and comprehensive care plans for the residents involved.
Unsanitary Food Storage in Walk-In Freezer
Penalty
Summary
The facility failed to store food in a sanitary manner in the main kitchen's walk-in freezer. During an observation on August 5th, frost buildup was noted on shelves and packages, with three fans covered in frost. One fan had a drip tray beneath it with icicles present, while two other fans had icicles without drip trays. Ice and frost buildup were also observed on three unopened boxes of crinkle cut carrots directly below the fans. A dietary assistant mentioned that parts were ordered for a needed repair. On a subsequent observation on August 7th, the frost buildup persisted, and the necessary parts for the condenser were still not available, as confirmed by an administrative dietary staff member.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection prevention and control standards, particularly in the use of enhanced barrier precautions (EBP), personal protective equipment (PPE), and hand hygiene. Several instances were observed where staff did not perform hand hygiene after removing soiled gloves and before applying new ones. For example, a certified nurse aide (CNA) did not perform hand hygiene after removing gloves following perineal care for a resident, and a nurse failed to perform hand hygiene between glove changes during a dressing change for a resident with a history of multidrug-resistant organism (MDRO) infection and pressure ulcers. Additionally, the facility did not consistently apply EBP for residents with indwelling devices or draining wounds. A resident with a draining hematoma was not placed on EBP until later in the day, despite the presence of drainage noted in the medical record. Another resident with a foley catheter was observed without EBP in place, and an administrative nurse confirmed the oversight. Furthermore, staff were unsure about the requirement to wear PPE when providing care to a resident with a peripherally inserted central catheter (PICC) line, indicating a lack of clarity and adherence to infection control protocols. The observations and interviews with staff highlighted a pattern of non-compliance with infection control policies, including the failure to disinfect surfaces contaminated with bodily fluids and improper handling of contaminated items. These deficiencies in infection control practices have the potential to spread infections within the facility, as evidenced by the multiple instances of inadequate hand hygiene and PPE use during resident care activities.
Failure to Obtain Physician Orders and Notify of Treatment Refusals
Penalty
Summary
The facility failed to provide care in accordance with professional standards for two residents. For Resident #29, a nurse applied Ready wraps to the resident's legs without obtaining a physician's order and did not notify the physician when the resident refused to wear the protective sock liners. The physical therapy notes indicated that the resident's skin was too fragile to wear the Ready wraps without the liners, which could lead to skin tears. Despite this, the nursing staff did not communicate the refusal to the physician or the physical therapy team, as expected by the facility's administrative staff. For Resident #41, the facility did not obtain a physician's order for a dressing change on the resident's right lower leg, which had a hematoma that required monitoring. The resident was observed with a dressing on the leg, and during a dressing change, a nurse applied a non-adhesive dressing and a protective wrap without a documented order. An administrative nurse confirmed the lack of an order for the dressing change, indicating a failure to adhere to professional standards of care.
Failure to Clarify Oral Intake Orders and Update Swallowing Evaluation
Penalty
Summary
The facility failed to restore oral eating skills for a resident with a gastrostomy tube and orders for oral intake. The resident, who had severe oropharyngeal dysphagia following a stroke, was on an NPO diet but was allowed pleasure feedings of pureed foods and nectar thick liquids by spoon twice daily. Despite the resident's high risk of aspiration, as noted in a physician's note and a nutrition support assessment, the facility did not clarify conflicting oral intake orders or obtain an updated speech therapy evaluation for two years. The resident's medical record showed a history of pneumonitis due to inhalation of food and vomit, and a speech therapy discharge note recommended pleasure feedings of ice cream and nectar thick liquids by spoon. However, the facility did not update the speech therapy evaluation since the initial assessment. A staff nurse confirmed that the resident was supervised during afternoon snacks due to a history of aspiration and a failed swallowing exam, yet the facility did not address the conflicting orders or reassess the resident's swallowing capabilities.
Infection Control Lapse in Tracheostomy Care
Penalty
Summary
The facility failed to ensure appropriate infection control practices for a resident receiving oxygen via a tracheostomy. During an observation, it was noted that the oxygen humidifier and tracheostomy collar mask oxygen tubing for the resident were resting on the floor. A certified nurse aide (CNA) was observed picking up the oxygen tubing from the floor and connecting it to the resident's tracheostomy collar mask. The CNA acknowledged that the tubing was on the floor and mentioned that attempts to keep it off the floor by hanging it on the bed rail or bedside table were unsuccessful. The resident involved had a medical history that included paralysis of vocal cords and larynx, acute respiratory failure with hypoxia, and tracheostomy status. The physician's orders required oxygen at 4 liters through a trach shield with humidification, and the care plan highlighted the need for contact precautions and good hand hygiene due to the tracheostomy. An administrative member confirmed that the expectation was for oxygen supplies to be stored in a bag and kept off the floor, indicating a failure to adhere to these infection control practices.
Failure to Conduct Timely AIMS Assessments for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that the medication regimen for three residents remained free of unnecessary medications, specifically concerning the use of antipsychotic medications. Resident #21 was prescribed risperidone in August 2023, but the medical record showed only one Abnormal Involuntary Movement Scale (AIMS) assessment completed in December 2023, with no subsequent assessments every six months as expected. An AIMS assessment was only completed on August 6, 2024, after a request for documentation. Resident #66, who was prescribed olanzapine in June 2024, had an AIMS assessment completed approximately two months later, on August 7, 2024, indicating a delay in the initial assessment. Resident #68 was prescribed chlorpromazine three times daily starting in May 2024, but the record lacked any AIMS assessment at the initiation of the medication. During an interview, an administrative nurse acknowledged the absence of a policy for AIMS assessments and stated that staff were expected to complete a baseline AIMS when a resident started on an antipsychotic medication and then every six months. The lack of timely and regular AIMS assessments for these residents indicates a failure to monitor for abnormal involuntary movements, which is crucial when administering antipsychotic medications.
Failure to Timely Report Serious Injury Incident
Penalty
Summary
The facility failed to report an incident of serious bodily injury to the State Survey Agency (SSA) within the required timeframe. A resident with severely impaired cognition experienced a fall from a mechanical lift, resulting in two facial lacerations and necessitating a trip to the emergency room. The incident occurred at approximately 7:00 p.m., but the initial report was not submitted to the SSA until approximately 19 hours later, which is beyond the mandated 2-hour reporting window for events involving serious bodily injury. The facility's policy on abuse, neglect, and exploitation requires that all incidents involving serious bodily injury be reported immediately, but not later than 2 hours after the event. Despite this policy, the administrative nurse and social service director confirmed that the report was delayed. The delay in reporting the incident to the SSA and facility administration constitutes a failure to comply with regulations designed to protect residents.
Failure to Document and Perform Post-Fall Assessments
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable physical well-being for a resident who experienced a fall from a mechanical lift, resulting in a facial laceration. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including dementia and osteoarthritis, who required a mechanical lift and two staff for transfers. During a transfer, the resident fell from the lift, sustaining facial lacerations. The facility's policy required immediate documentation of falls and neurological assessments, but the documentation was delayed by 15 hours, and the initial neurological assessment was incomplete. The medical record lacked documentation of vital signs and further neurological assessments post-fall, and there were no orders to discontinue these assessments. Interviews with facility staff revealed that the expected protocol was not followed, as the staff nurse admitted to failing to document the neurological assessments in the electronic health record (EHR) and not completing additional assessments as required by policy. The administrative nurse confirmed the lack of documentation and emphasized the expectation for timely and accurate record-keeping following such incidents.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Minot
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Minot Health And Rehab, Llc | 0.9 mi | ★★★★★ | 5 | 0 |
| Souris Valley Care Center | 21.2 mi | ★★★★★ | 6 | 1 |
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