Trinity Homes (SFF) Abuse and Neglect Attorneys

Both the State of North Dakota and the Centers for Medicare and Medicaid Services (CMS) conduct routine surveys, investigations, and inspections of every nursing home statewide. The efforts of the surveyors and investigators help to identify serious concerns, deficiencies, and violations. When problems are detected, regulators provide the nursing home guidance on how to adjust their policies and procedures and improve the quality of care they provide every resident.

Some concerns are so egregious that regulators will deem the facility a Special Focus Facility (SFF) and add the Home to the federal Medicare deficiency watch list. These facilities are placed on notice and remain under the watchful eye of the federal and state governments. Typically, the facility will remain on the watch list for many years until regulators are assured that all improvements are permanent.

In late 2017, regulators designated Trinity Homes a Special Focus Facility. Now that the Home has been added to the watch list, they will undergo additional surveys and unannounced inspections each year. Some of the most recent concerns, hazards, deficiencies, and violations involving this facility are detailed below.

Trinity Homes (SFF)

This facility is a “not for profit” 230-certified bed long-term care Center providing services to the residents of Minot and Ward County, North Dakota. The Home is located at:

305 8th Ave. NE.
Minot, ND 58702
(701) 857-5800

In addition to providing skilled nursing care, the facility also offers:

  • Cardiopulmonary rehabilitation
  • Hospice care
  • Orthopedic care
  • Joint replacement rehab
  • Physical therapy
  • Palliative medicine
More Than $24,000 in Monetary Penalties

State and federal nursing home regulators have the legal authority to impose monetary penalties against any convalescent facility identified with violations and deficiencies. These fines are meant to deter unacceptable staff performance and alert the public of nursing homes in the community that provide substandard care.

Over the last three years, regulators and have imposed one monetary penalty against Trinity Homes. This $24,703 fine was issued on February 22, 2017. During the same time, the state received nine formally filed complaints involving this facility that after investigations all resulted in citations.

Current Nursing Home Safety Concerns

The state of North Dakota routinely updates their long-term convalescent home database system to reflect dangerous safety concerns, health violations, resident hazards, filed complaints, opened investigations, and incident inquiries. This information can be located on various websites including Medicare.gov.

Currently, Trinity Homes maintains an overall two out of five stars compared to all nursing homes in the United States. This ranking includes one out of five stars for health inspections, five out of five stars for staffing issues, and three out of five stars for quality measures. Some serious concerns, violations, and deficiencies occurring at this facility include:

  • Failure to Ensure That Every Resident Remained Free from Physical Restraints Unless it is Necessary for Medical Treatment
  • In a summary statement of deficiencies dated March 10, 2016, the state investigator documented the facility’s failure to ensure one resident observed in a rock-and-go wheelchair remained free of physical restraints.” The deficient practice by the nursing staff “to assess the chair that prevented rising as the least restrictive option, obtain a physician’s orders, and obtain families consent, placed the resident and all residents using a rock-and-go wheelchair at risk of injury and loss of mobility.”

  • Failure to Notify the Resident’s Doctor Immediately of a Serious Decline in Their Medical Condition That Jeopardizes Their Health
  • In a summary statement of deficiencies dated December 2, 2015, the state investigator documented that the facility had “failed to ensure timely physician notification [for a resident] identified with pain.” The deficiency involved a “failure to notify the physician of [the resident’s] pain that resulted in delayed treatment, and pain management.”

    This incident involved a review a resident’s records and a Hospital Discharge Summary Report dated January 6, 2015, that noted: “current pain medications included Tylenol 1000 mg three times a day as needed (PRN).” The pain medication was used to treat the onset of pain on the resident’s left groin involving a large tender lump. The resident’s Progress Note revealed that starting on February 9, 2015, at 9:38 AM, a nurse again faxed [the resident’s] physician regarding the left groin.” Further review reflected “that the physician did not respond to either fax.”

  • Failure to Ensure That Every Resident Receives an Accurate Assessment by a Qualified Health Professional
  • In a summary statement of deficiencies dated December 2, 2015, the state surveyor documented the facility’s failure “to ensure that the Minimum Data Set (MDS) accurately reflected the resident’s status.” The deficiency by the nursing staff “to accurately assess [the resident] regarding delusions and code the MDS correctly does not reflect the resident’s current status and may affect the accuracy of the Care Plan [involving] the level of care provided to the resident.”

  • Failure to Report and Investigate Acts or Allegations of Abuse, Neglect or Mistreatment of Residents [recurring deficiency]
  • In a summary statement of deficiencies dated February 12, 2016, the state investigator documented the facility’s failure “to provide the necessary supervision to prevent accidents [for residents] with a history of falls. Failure to consistently implement fall prevention measures (i.e., leaving a resident’s room door open) may result in avoidable falls and injuries.”

    One incident involved a review of a Falls Documentation Form dated December 16, 2014, that “identified a fall which occurred in [the resident’s] room. The form stated, ‘what adjustments are being made?’. Will leave the door open so staff can see the resident when the staff walked past her room.” However, the Falls Documentation Form dated six days later, on December 22, 2015, “identified another fall which occurred in [the resident’s] room.”

    The surveyor documented that on multiple observations “throughout the afternoons of February 9, 2015, February 10, 2015, showed the door to [the resident’s] room remained closed, even when the staff was not present in the room.” At 3:05 PM on February 10, 2015, “an unidentified staff nurse entered [the resident’s] room to offer the resident a supplement. The nurse then left [the resident’s] room and pulled the door shut behind her.”

    In a separate summary statement of deficiencies dated March 10, 2016, the state investigator documented the facility’s failure “to thoroughly investigate a potential abuse or neglect incident for [a resident] who sustained a fall from a mechanical lift.” The deficient practice by the nursing staff “to thoroughly investigate a fall, including an interview with the resident, has the potential to place all residents at risk for abuse and neglect.”

  • Failure to Ensure Residents Receive Proper Treatment to Prevent New Bedsores or Healed Existing Pressure Sores [recurring deficiency]
  • In a summary statement of deficiencies dated March 10, 2016, the state investigator documented the facility’s failure “to provide interventions to prevent the development/deterioration of pressure ulcers for [one resident] with the pressure ulcer.” The deficient practice by the nursing staff to “consistently implement pressure ulcer prevention interventions (reposition [the resident’s body], moisture barrier cream) may result in the deterioration of [the resident’s] pressure ulcer and the development of additional skin breakdown.”

    In a separate summary statement of deficiencies dated February 22, 2017, the state investigator documented the facility’s failure “to provide the necessary treatment and services to prevent the development of pressure ulcers for [three residents].” The deficient practice by the nursing staff “to implement preventative measures resulted in [two residents] developing pressure ulcers on their heels, and placed [a third resident] at risk for developing an ulcer.”

  • Failure to Provide Care to Residents Requiring Special Services [recurring deficiency]
  • In a summary statement of deficiencies dated February 12, 2016, the state investigator documented the facility’s failure “to provide the necessary care and services for [a resident] that required oxygen.” The deficient practice by the nursing staff “to provide oxygen as ordered/as necessary to maintain appropriate oxygen levels has the potential for [the resident] to experience complications or hospitalization related to low oxygen saturation levels.”

    In a second summary statement of deficiencies dated October 13, 2016, the state investigator documented the facility’s failure “to safely secure an oxygen tank in [a resident’s room].” The deficient practice by the nursing staff to “secure the oxygen tank placed the facility’s residents, visitors, and staff at risk of injury in the event of an unsecured tank fall that becomes a projectile object.”

    In a third summary statement of deficiencies dated March 10, 2016, the state investigator documented the facility’s failure “to provide the necessary care and services for [a resident] with orders for continuous oxygen.” The deficient practice by the nursing staff “to provide oxygen as ordered has the potential for residents to experience complications related to inadequate oxygen saturation levels.”

    In a fourth summary statement of deficiencies dated October 13, 2016, the state investigator documented the facility’s failure to ensure a resident observed during a “medication pass received necessary care and services.” The deficient practice by the nursing staff “to provide proper repositioning has the potential to affect the resident’s overall swallow safety, putting them at risk of aspiration [the inability to draw a breath].”

    This incident was observed on the morning at October 12, 2016, when a Certified Nursing Assistant raised a resident’s “bed to an approximate 50° angle and offered her a drink of thickened, water, which the resident swallow.” However, the staff failed to raise three other resident’s beds “to an approximate 90° angle [before] offering liquids, placing them at risk of aspiration.” The surveyor discussed with the administrative staff members safety issues involving positioning in swallowing. The staff members in attendance “provided no additional information.”

  • Failure to Follow Protocols and Procedures to Prevent the Spread of Infection throughout the Facility [recurring deficiency]
  • In a summary statement of deficiencies dated February 12, 2016, the state investigator documented the facility’s failure “to ensure staff performs proper hand hygiene and glove usage for [three residents] observed [to have received] administered eyedrops.” The deficient practice by the nursing staff “to follow infection control practices including proper hand hygiene and glove usage during the administration of eyedrops has the potential to spread the infection to other residents, family, visitors, and staff.”

    In a separate summary statement of deficiencies dated October 13, 2016, the state surveyor documented the facility’s failure to “follow infection control practices for [two residents].” This incident involved observations made by the surveyor “during an initial tour on October 12, 2016, at 10:05 AM.”

    The surveyor observed a housekeeping staff member standing in the hallway “outside the resident’s room with isolation gown on. The housekeeping staff member stated she applied the isolation down to clean the isolation room. She said she entered the resident’s room, left the room to obtain a rag, moved the housekeeping cart up the hallway for another housekeeper, and returned to the resident’s room. The housekeeping staff member failed to remove the isolation gown and perform hand hygiene [before] exiting the room.”

    In a third summary statement of deficiencies dated March 10, 2016, the state investigator documented the facility’s failure “to follow infection control practices for [12 residents].” The deficient practice by the nursing staff “to follow infection control practices related to [intestinal issues and] precautions for a resident, [and] droplet precautions for [another resident].” The staff failed to follow infection safeguard protocol for handling “dressing changes [for a third and fourth resident], and hand hygiene/perineal care [for nine residents] has the potential to spread the infection to other residents, staff and visitors.”

    In a fourth summary statement of deficiencies dated February 22, 2016, the state investigator documented the facility’s failure “to follow infection control practices for [two residents] observed during dressing changes.” The deficient practice by the nursing staff “to follow infection control practices related to hand hygiene during and after dressing changes and cleaning of equipment (mechanical lift) has the potential to spread the infection to other residents, staff and visitors.”

  • Failure to Provide an Environment Free of Accident Hazards [recurring deficiency]
  • In a summary statement of deficiencies dated October 13, 2016, the state investigator documented the facility’s failure “to provide adequate supervision and assistive devices for [three residents, including one who fell and sustained a] fracture.

    The deficient practice by the nursing staff “to implement interventions correctly and consistently, evaluate the effectiveness of interventions, modify/replace interventions as needed, and evaluate the effectiveness of new interventions, resulted in [the resident] experiencing additional falls with injury.” This deficiency might also have resulted in two of the residents “experiencing additional falls with or without injury.”

    In a second summary statement of deficiencies dated March 10, 2016, the state investigator documented the facility’s failure “to provide adequate supervision and assistive devices for [5 resident’s] with histories of falls.” The deficient practice by the nursing staff to “ensure proper use of a gait belt, appropriate transfer method, and re-evaluate the use of a fall intervention has the potential for all residents to experience unnecessary falls, injury, and pain.”

    In a third summary statement of deficiencies dated February 22, 2017, the state investigator documented the facility’s failure “to maintain a safe environment (chemicals used by housekeeping staff) when cleaning the facility.” This deficiency “of leaving the housekeeping chemicals unattended placed cognitively impaired/wandering residents at risk for accidents and injury

  • Failure to Ensure That Every Resident Receives a Nutritional, Well-Balanced Diet Unless Not Possible [recurring deficiency]
  • In a summary statement of deficiencies dated October 13, 2016, the state investigator documented the facility’s failure to ensure one closed record for a resident “identified as having significant weight loss revealed necessary care and services [promptly] to maintain his weight.” The deficient practice by the nursing staff to ensure the resident “received assistance as needed may have contributed to his continued weight loss.”

    In a separate summary statement of deficiencies dated February 22, 2017, a state investigator documented the facility’s failure “to adequately assess the nutritional intake and follow interventions to restore/maintain adequate nutritional status for [one resident] who experienced weight loss.” The deficient practice by the nursing staff to “meet the resident’s nutritional needs throughout diet, supplements and other interventions may have contributed to the resident experiencing significant weight loss.”

Need an Attorney for Your Nursing Home Neglect Claim?

If your loved one suffered harm while residing at Trinity Homes, or any other nursing facility, hiring a personal injury attorney could be a wise decision. With legal representation, your lawyer will provide immediate services without the need of making an upfront payment. These types of cases are handled through contingency fee agreements with an arrangement to postpone paying fees until after the case is resolved successfully, and you have obtained financial compensation to recover your damages.

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