Trinity Homes

    305 8th Ave NE, Minot, ND 58703
    • Assisted Living
    • Memory Care
    • Skilled Nursing

    Compassionate spacious care with warmth

    I placed Aunt Joan here and the staff provided very good, compassionate care that made her final months comfortable. The facility is spacious with ground-floor gathering areas where kids can run without disturbing others. Staff were friendly and helpful - I often heard a nursing assistant singing and saw residents smiling and affectionate. Overall, I'm very pleased with the care.

    Loved one of resident
    Jul 2026

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (non-medical)

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    Reviews

    2.62·(21)

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      2.6
    • Staff

      2.3
    • Meals

      2.6
    • Amenities

      2.0
    • Value

      1.0

    Pros

    • Compassionate nursing and caregiver interactions
    • Friendly, helpful staff
    • Comfortable, dignified end-of-life care
    • Affectionate staff–resident engagement
    • Spacious common areas and ground-floor family space
    • Ability to host family gatherings
    • On-site physical and occupational therapy services
    • Positive short-term rehabilitation outcomes

    Cons

    • Inconsistent clinical care quality
    • Chronic understaffing and high staff turnover
    • Gaps in medication administration and documentation
    • Weak discharge-planning and family-communication processes
    • Inadequate wound-care and infection-prevention practices
    • Poor building maintenance and dated, dim interior aesthetics
    • Insufficient and inconsistent activity programming
    • Unreliable call-bell response and resident-assistance systems
    • Staff conduct and responsiveness
    • Allegations of theft and overcharging

    Summary of reviews

    Reviewer feedback for Trinity Homes is mixed, showing a facility that delivers clear strengths in interpersonal care while also exhibiting recurring operational weaknesses. Several families described warm, compassionate interactions from nursing assistants and other caregivers, noting moments of affectionate, engaging behavior (singing, smiling residents, and helpful staff). Some short-term rehabilitation stays were described as effective, and the building’s ground-floor and common spaces were repeatedly praised for being spacious and family-friendly, allowing gatherings and intergenerational visits.

    At the same time, reviewers raised substantive concerns about consistency of clinical care. Descriptions indicate variability in how clinical issues are managed: medication administration and documentation were identified as unreliable in multiple accounts, and reviewers reported shortcomings in wound care and infection-prevention practices. Several families said they needed to advocate to obtain clinical results or adequate follow-up, and there were reports of inadequate discharge instructions and unresponsive communication from staff and leadership.

    Staffing and management emerged as central themes. Many comments point to chronic understaffing, high staff turnover, and staffing gaps in specific services such as physical therapy. Those workforce challenges appear to affect responsiveness (including call-bell response), continuity of care, and the consistency of activity programming. Reviewers also described concerns about management decisions and leadership style, which some families linked to staff morale and personnel changes.

    Facility condition and programmatic offerings are described as uneven. Positive notes about spacious common areas and the ability to host family events coexist with descriptions of dated décor, worn carpeting, dim interiors, and sanitation concerns in certain areas. Activity programming was praised in some interactions but described as neglected or inconsistent by others, suggesting variability across units or shifts.

    Safety and conduct issues were raised with enough frequency and specificity to merit attention from prospective families. Beyond the clinical concerns already noted, reviewers described problems with call-bell reliability, bed placement practices, confidentiality lapses involving an individual clinician on a specified unit, and serious financial concerns described as alleged theft and overcharging. While some accounts praised attentive, compassionate caregivers and positive outcomes for particular residents, other accounts described significant lapses that resulted in families choosing alternate providers.

    In summary, Trinity Homes appears to offer genuine strengths in staff compassion, family-friendly spaces, and rehabilitation capability, but those positives are tempered by recurring operational issues: inconsistent clinical quality, staffing shortfalls, management and communication weaknesses, facility upkeep needs, and a handful of serious allegations. Families considering Trinity Homes should weigh the facility’s interpersonal strengths against these operational patterns, ask targeted questions about staffing levels, wound care protocols, medication administration procedures, call-system reliability, and financial practices, and seek recent, unit-specific observations or references before making a placement decision.

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    Medicare Ratings

    1·/ 5
    Cited by CMS for abuse, or potential for abuse, on its most recent survey cycle.
    • Overall

    • Health Inspection

    • Staffing

    • Quality Measures

    Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov

    Location

    Map showing location of Trinity Homes

    Trinity Homes is located at 305 8th Ave NE, Minot, ND, 58703.

    About Trinity Homes

    Trinity Homes is a care facility dedicated to providing a supportive and compassionate environment for its residents. Known for its commitment to high-quality care and a warm community atmosphere, Trinity Homes serves individuals who require assistance with daily living while also promoting a sense of independence and dignity. The care home strives to create a meaningful experience for residents, enriching everyday life with engaging activities and opportunities for connection.

    The staff at Trinity Homes is attentive to the needs of each resident, fostering strong relationships and prioritizing personalized care. Family and friends are encouraged to maintain active involvement in the lives of their loved ones residing at Trinity Homes. The facility recognizes the importance of communication and offers avenues for families to send messages, ensuring that residents feel supported and valued by those who matter most to them. Community values are at the heart of Trinity Homes, and every effort is made to cultivate a sense of belonging and emotional well-being among residents.

    Trinity Homes also pays special attention to creative and therapeutic activities, helping residents express themselves and remain engaged. The facility values innovative approaches to understanding residents’ experiences and supports initiatives that enhance both mental and emotional health. The wellbeing of each individual is of utmost importance, and the staff is dedicated to making Trinity Homes a place where people feel safe, understood, and cared for every day.

    With a focus on holistic care, Trinity Homes ensures that residents experience not just assistance with everyday needs, but also opportunities for socialization, personal fulfillment, and meaningful interaction. The facility combines experience, compassion, and a welcoming atmosphere, making it a trusted residence for those seeking a supportive community in a home-like setting.

    People often ask...

    Trinity Homes offers assisted living, memory care, and skilled nursing.

    There are 2 photos of Trinity Homes on Mirador.

    The full address for this community is 305 8th Ave NE, Minot, ND 58703.

    No, Trinity Homes does not offer respite care. Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.

    Safety & Compliance

    In North Dakota, Health & Human Services' Health Facilities unit licenses care facilities and publishes the health and life-safety deficiencies found during inspections.

    License numberSNF-trinity-homes-minot
    Facility typeSkilled Nursing Facility

    Inspection Reports

    54

    Reports

    188

    Citations

    0

    Complaints

    16

    Years

    19 Nov 2025Inspection
    Investigated a transport incident and found a resident was not secured with the shoulder strap during van transport, resulting in a leg fracture.
    • CFR 483.25(d)(1)-(2)Free of Accident Hazards/Supervision/Devices
    20 May 2025Inspection
    Investigated a sexual abuse incident involving two cognitively impaired residents and found failures to protect them from abuse.
    • CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
    13 Nov 2024Inspection
    Investigated a complaint and found no deficiencies. Determined compliance with regulatory requirements.
    05 Sept 2024Inspection
    Investigated abuse and dementia care concerns; a memory care resident demonstrated ongoing verbal, physical, and sexual behaviors toward others, and there were failures to assess, plan, and monitor to prevent abuse and to provide adequate dementia care and meaningful activities.
    • CFR 483.12(a)(1)Free from Abuse and Neglect
    • CFR 483.40(b)(3)Treatment/Service for Dementia
    08 Aug 2024Inspection
    Investigation found multiple deficiencies related to care planning, professional standards of care, pressure ulcer prevention, and supervision during the survey period.
    • CFR 483.21(b)(2)(i)-(iii)Care Plan Timing and Revision
    • CFR 483.21(b)(3)(i)Care Plans—Professional Standards
    • CFR 483.25(b)(1)(i)-(ii)Pressure Ulcers—Prevention/Ttment
    • CFR 483.25(d)(1)-(2)Accidents—Hazards/Supervision/Devices
    06 Aug 2024Life Safety
    Identified several life-safety deficiencies, including two-hour fire resistance issues, unprotected vertical openings, fire alarm and sprinkler system maintenance lapses, inoperable smoke detectors, and excessive travel distances in smoke compartments.
    • NFPA 101, 2012 edition; 19.1.6Building Construction Type and Height
    • NFPA 101, 2012 edition; 19.3.1.1–19.3.1.6Vertical Openings - Enclosure
    • NFPA 70; NFPA 72; NFPA 72 14.2.1.2.2; NFPA 72 9.6.1.3; NFPA 70Fire Alarm System - Testing and Maintenance
    • NFPA 101 19.3.4.5.2; NFPA 72Smoke Detection
    • NFPA 25; NFPA 25 4.1.4.1; NFPA 25 13.6.2.1; NFPA 25 4.6.12Sprinkler System - Maintenance and Testing
    • NFPA 101, 19.3.7.1; 19.3.7.2Subdivision of Building Spaces - Smoke Compartments
    31 Jul 2024Inspection
    Investigated a resident fall with serious injury and related reporting and care deficiencies; found the event was not reported within the required timeframe and fall-related neuro/vital sign assessments were not completed or documented timely.
    • §483.12(b)(5)(i)(A)(B)(c)(1)(4)Reporting of Alleged Violations
    • §483.25Quality of Care
    02 Apr 2024Inspection
    Investigated reported incidents and complaints. Found no regulatory violations.
    29 Nov 2023Inspection
    Found no deficiencies. The investigation determined that regulatory requirements were met.
    12 Sept 2023Inspection
    Investigated a complaint and found no deficiencies.
    28 Aug 2023Life Safety
    Found multiple life safety deficiencies related to fire resistance, vertical openings, and smoke barrier travel distances. This indicates noncompliance with life safety code requirements.
    • NFPA 101 19.1.6.1Building Construction Type and Height
    • NFPA 101 19.3.1.1-19.3.1.6Vertical Openings - Enclosure
    • NFPA 101 19.3.7.1-19.3.7.2Subdivision of Building Spaces - Smoke Compartments
    24 Aug 2023Inspection
    Identified multiple deficiencies in pharmaceutical services, resident supervision, nutrition, and medication handling during a survey.
    • 33-07-03.2-18PHARMACEUTICAL SERVICES
    • 42 CFR 483.25(d)Free of Accident Hazards/Supervision/Devices
    • 42 CFR 483.25(g)Nutrition/Hydration Status Maintenance
    • 42 CFR 483.45(f)Medication Errors
    • 42 CFR 483.45(g)(h)(1)(2)Labeling/Storage of Drugs and Biologicals
    22 May 2023Inspection
    Found no deficiencies. The concerns raised in the complaint were unsubstantiated.
    01 Jun 2022Inspection
    Found no deficiencies following the focused oversight survey.
    31 May 2022Life Safety
    Identified life-safety deficiencies related to fire resistance of structural elements, vertical shaft enclosures, and smoke barrier travel distances.
    • NFPA 101 2012, 19.1.6.1Two-hour fire resistance rating for structural members
    • NFPA 101 2012, 19.3.1.1 through 19.3.1.6Vertical Openings - Enclosure
    • NFPA 101 2012, 19.3.7.1, 19.3.7.2Subdivision of Building Spaces - Smoke Compartments
    21 Apr 2022Inspection
    Identified multiple deficiencies across assessments, care planning, ADL support, tube feeding, medication labeling, food safety, and infection control.
    • CFR 483.20(g)Accuracy of Assessments
    • CFR 483.21(b)(2)Care Plan Timing and Revision
    • CFR 483.24(a)(2)ADL Care Provided for Dependent Residents
    • CFR 483.25(g)(4)-(5)Tube Feeding Mgmt/Restore Eating Skills
    • CFR 483.45(g)(h)(1)(2)Label/Store Drugs and Biologicals
    • CFR 483.60(i)(1)-(2)Food Procurement,Store/Prepare/Serve-Sanitary
    • CFR 483.80Infection Prevention & Control
    25 Feb 2021Inspection
    Identified deficiencies in resident assessments, insulin administration, and supervision during transfers that could affect resident safety and care.
    • CFR 483.20(g)Accuracy of Assessments
    • CFR 483.21(b)(3)(i)Comprehensive Care Plans – Meet professional standards
    • CFR 483.25(d)(1)(2)Free of Accident Hazards/Supervision/Devices
    08 Dec 2020Inspection
    Identified failure to notify the resident's family about a fall with injury and the subsequent emergency interventions.
    • §483.10(g)(14)Notify of Changes
    04 Dec 2020Inspection
    Found deficiencies in infection control, including inadequate PPE use when caring for a resident with suspected COVID-19 and failure to maintain a privacy curtain between roommates to prevent transmission.
    • 42 CFR 483.80Infection prevention and control
    10 Nov 2020Inspection
    Verified compliance with COVID-19 infection control requirements after a focused survey; no deficiencies were cited.
    21 Oct 2020Inspection
    Investigated a complaint and found failures in wound care management and documentation for pressure ulcers, including missing policy and weekly assessments.
    • CFR 483.25(b)(1)(i)(ii); 483.25(b); 483.25(b)(1)Treatment/Svcs to Prevent/Heal Pressure Ulcer
    25 Aug 2020Inspection
    Found no deficiencies related to infection control. Compliance with CMS/CDC COVID-19 guidelines was noted during the focused review.
    17 Mar 2020Inspection
    Found no deficiencies. The COVID-19 focused infection control review demonstrated compliance with infection control requirements and CMS/CDC practices.
    11 Mar 2020Life Safety
    Found life-safety construction deficiencies including lack of two-hour fire resistance for structural members and vertical openings, and excessive travel distance within smoke compartments.
    • NFPA 101 2012, 19.1.6.1, 19.1.6.4-19.1.6.7Building Construction Type and Height
    • NFPA 101 2012, 19.3.1.1-19.3.1.6Vertical Openings - Enclosure
    • NFPA 101 2012, 19.3.7.1-19.3.7.2Subdivision of Building Spaces - Smoke Compartments
    25 Apr 2019Inspection
    Found multiple deficiencies across care planning, resident assistance, oxygen management, tube feeding, behavioral health, food handling, and infection control, indicating failures to update plans, provide needed care, follow orders, and maintain infection prevention.
    • 483.21(b)(2)Care Plan Timing and Revision
    • 483.24(a)(2)ADL Care Provided for Dependent Residents
    • 483.25(d)Free of Accident Hazards/Supervision/Devices
    • 483.25(g)(4)-(5)Tube Feeding Mgmt/Restore Eating Skills
    • 483.25(i)Respiratory/Tracheostomy Care and Suctioning
    • 483.40Behavioral Health Services
    • 483.60(i)Food Procurement,Store/Prepare/Serve-Sanitary
    • 483.80Infection Prevention & Control
    02 Apr 2019Life Safety
    Identified multiple life-safety deficiencies related to building construction, vertical shaft enclosures, and smoke compartment travel distances, with some mitigated through a fire safety evaluation system.
    • NFPA 101 Building Construction Type and Height (2012)Building Construction Type and Height
    • NFPA 101 Vertical Openings - Enclosure (2012) 19.3.1.1-19.3.1.6Vertical Openings - Enclosure
    • NFPA 101 19.3.7.1, 19.3.7.2 (Subdivision of Building Spaces - Smoke Compartments) (2012)Subdivision of Building Spaces - Smoke Compartments
    18 Oct 2018Inspection
    Investigated multiple deficiencies across resident care, safety, infection control, and record-keeping, including code status accuracy, care plans, falls and injuries, infections, and staffing.
    • §483.10(c)(6) and §483.10(g)(12)Right to refuse/take part in care and advance directives
    • §483.20(e)Coordination of PASARR and Level II assessments
    • §483.21(b)(2)(iii)Care plans and interdisciplinary review
    • §483.21(b)(3)Services provided meet professional standards
    • §483.25(a)Vision and hearing care
    • §483.25(d)Accidents; supervision and devices
    • §483.25(e)Incontinence care and catheter use
    • §483.25(i)Respiratory care and oxygen management
    • §483.35(a)(1)-(2)Staffing sufficient to meet resident needs
    • §483.45(g)-(h)Drug labeling and storage; controlled substances
    • §483.60(i)Food safety; storage and preparation
    • §§483.80(a)-(f)Infection prevention and control
    03 Oct 2018Life Safety
    Identified multiple life-safety deficiencies including unprotected structural members, unenclosed vertical openings, and issues with fire alarm testing, smoke detection placement, and smoke compartment travel distances.
    • NFPA 101 2012 19.1.6.1; 19.1.6.4-19.1.6.5Building Construction Type and Height
    • NFPA 101 2012 19.3.1.1–19.3.1.6Vertical Openings - Enclosure
    • NFPA 101 2012 9.6.1.3; NFPA 70; NFPA 72Fire Alarm System - Testing and Maintenance
    • NFPA 101 2012 19.3.4.5.1–19.3.4.5.2; NFPA 72 9.6.2.10.1.1; NFPA 72 17.7.4.1Smoke Detection
    • NFPA 101 2012 19.3.7.1–19.3.7.2Subdivision of Building Spaces - Smoke Compartments
    05 Apr 2018Inspection
    Found multiple deficiencies across resident rights, care planning, safety, nutrition, staffing, lab, food service, and infection control. These deficiencies showed care did not meet professional standards.
    • CFR 483.10Resident Rights/Exercise of Rights
    • CFR 483.21(b)(2)Care Plan Timing and Revision
    • CFR 483.21(b)(3)(i)Services Provided Meet Professional Standards
    • CFR 483.24(a)(2)ADL Care Provided for Dependent Residents
    • CFR 483.25Quality of Care
    • CFR 483.25(d)Free of Accident Hazards/Supervision/Devices
    • CFR 483.25(n)Bed Rails
    • CFR 483.35(a)(1)-(2)Sufficient Nursing Staff
    • CFR 483.50(a)Laboratory Services
    • CFR 483.60(i)(1)-(2)Food Procurement,Store/Prepare/Serve-Sanitary
    • CFR 483.80Infection Prevention & Control
    08 Mar 2018Life Safety
    Identified multiple life-safety code deficiencies in the main building, including inadequate fire resistance, unprotected vertical openings, sprinkler head rating issues, corridor separation gaps, and excessive travel distances to smoke barriers. A fire safety evaluation system was used to evaluate some deficiencies.
    • NFPA 101, Building Construction Type and Height, 2012 Edition; 19.1.6.4, 19.1.6.5Two-hour fire resistance for structural components
    • NFPA 101, 19.3.1.1 through 19.3.1.6Vertical Openings - Enclosure
    • NFPA 101 19.3.5.1; 9.7.1.1(1); NFPA 13 8.3.2, 8.3.2.5(10)Sprinkler System - Installation
    • NFPA 101 18.3.6.1; 19.3.6.1Corridors - Areas Open to Corridor
    • NFPA 101 19.3.7.1; 19.3.7.2Subdivision of Building Spaces - Smoke Compartments
    22 Feb 2017Inspection
    The investigation identified widespread deficiencies affecting resident dignity, care planning, safety, nutrition and hydration, staffing transparency, medication handling, infection control, and related practices, placing residents at risk of harm.
    • 483.10(a)(1)DIGNITY AND RESPECT OF INDIVIDUALITY
    • 483.10(e)Respect and Dignity
    • 483.24(c)(1)ACTIVITIES MEET INTERESTS/NEEDS OF EACH RESIDENT
    • 483.20(g)(h)(i)(j)ACCURACY OF ASSESSMENTS
    • 483.10(c)(2)RIGHT TO PARTICIPATE IN PLANNING CARE-REVISE CP
    • 483.21(b)(3)(i)COMPREHENSIVE CARE PLANS
    • 483.24, 483.25(k)(l)QUALITY OF LIFE/QUALITY OF CARE
    • 483.25(b)(1)SKIN INTEGRITY/ULCER PREVENTION
    • 483.25(d)(1)(2)(n)(1)-(3)FREE OF ACCIDENT HAZARDS/ SUPERVISION/ DEVICES
    • 483.25(g)(1)-(4)MAINTAIN NUTRITION STATUS
    • 483.25(g)(2)SUFFICIENT FLUID TO MAINTAIN HYDRATION
    • 483.35(g)(1)-(4)POSTED NURSE STAFFING INFORMATION
    • 483.95(h)FEEDING ASSISTANTS
    • 483.45(b)(2)(3)(g)(h)DRUG RECORDS/LABEL/STORE DRUGS & BIOLOGICALS
    • 483.80(a)(1)(2)(4)(e)(f)INFECTION CONTROL
    15 Nov 2016Life Safety
    Identified multiple life safety deficiencies, including inadequate fire resistance for structural elements, unsafe vertical openings, improper smoke compartment travel distances, incorrect sprinkler head types, and missing risk assessment.
    • NFPA 101 2012, 19.1.6.1Two-hour fire resistance rating for structural members
    • NFPA 101 2012, 19.3.1.1-19.3.1.6Vertical openings - enclosure
    • NFPA 13; NFPA 101 19.3.5.1, 9.7.1.1(1); 8.3.2.1Sprinkler system installation
    • NFPA 101 2012, 19.3.7.1-19.3.7.2Subdivision of building spaces - smoke compartments
    • NFPA 99 2012, 4.2Fundamentals - Building System Categories
    13 Oct 2016Inspection
    Multiple deficiencies were found across dignity, planning of care, safety, nutrition, infection control, and related services, indicating residents did not consistently receive care that protects dignity, safety, and well-being.
    • 483.15(a)DIGNITY AND RESPECT OF INDIVIDUALITY
    • 483.15(g)(1)PROVISION OF MEDICALLY RELATED SOCIAL SERVICE
    • 483.20(d)(3), 483.10(k)(2)RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP
    • 483.25PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING
    • 483.20(d)(3), 483.10(k)(2)FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
    • 483.25(i)MAINTAIN NUTRITION STATUS
    • 483.25(k)TREATMENT/CARE FOR SPECIAL NEEDS
    • 483.65INFECTION CONTROL, PREVENT SPREAD, LINENS
    10 Mar 2016Inspection
    An inspection identified multiple deficiencies across resident rights, dignity, care planning, infection control, and clinical care, indicating several areas where requirements were not met.
    • 483.10(b)(5)-(10), 483.10(b)(1)NOTICE OF RIGHTS
    • 483.10(i)(1)RIGHT TO PRIVACY - SEND/RECEIVE UNOPENED MAIL
    • 483.13(a)RIGHT TO BE FREE FROM RESTRAINTS
    • 483.13(c)ABUSE/NEGLECT POLICIES
    • 483.15(a)DIGNITY AND RESPECT OF INDIVIDUALITY
    • 483.10(k)(2)REASONABLE ACCOMMODATION OF NEEDS/PREFERENCES
    • 483.20(b)(1)COMPREHENSIVE ASSESSMENTS
    • 483.20(b)(2)(ii)COMPREHENSIVE ASSESS AFTER SIGNIFICANT CHANGE
    • 483.20(b)(3)PARTICIPATION IN PLANNING CARE - REVISIT CP
    • 483.25PAIN MANAGEMENT
    • 483.25(d)NO CATHETER, PREVENT UTI, RESTORE BLADDER
    • 483.25(k)PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING
    • 483.25TREATMENT/CARE FOR SPECIAL NEEDS
    • 483.25RESIDENTS FREE OF SIGNIFICANT MED ERRORS
    • 483.65INFECTION CONTROL, PREVENT SPREAD, LINENS
    20 Jan 2016Life Safety
    Identified multiple life safety code deficiencies related to fire resistance, shaft enclosures, smoke compartment travel distances, and sprinkler coverage.
    • NFPA 101 19.1.6.2Two-hour fire resistance rating not maintained for structural members
    • NFPA 101 19.3.1.1Two-hour fire resistive rating not maintained for elevator shafts
    • NFPA 101 19.3.7.1Travel distance to door in smoke compartments exceeds 200 feet
    • NFPA 101 19.3.5, NFPA 19.3.5.1; NFPA 13Sprinkler system not installed per NFPA 13
    12 Feb 2015Inspection
    An investigation found deficiencies related to notification and contact information for residents’ representatives, accuracy of the resident assessment data, compliance with professional standards, and pain management documentation and processes.
    • Notification/Resident Representative Information
    • MDS Accuracy
    • Professional Standards
    • Pain Management
    • Pain Management (Follow-up)
    03 Dec 2014Life Safety
    Observed several life-safety deficiencies related to fire resistance, shaft protection, and smoke-area travel distances; an evaluation method was used for some items but did not meet the standard for all components.
    • NFPA 101 Life Safety Code – Two-hour fire resistance rating required for structural members and ceiling/roof assembliesTwo-hour fire-resistance rating not maintained
    • NFPA 101 Life Safety Code – Travel distance within smoke barriersTravel distance within smoke barriers not within limits
    • NFPA 101 Life Safety Code – Travel distance and smoke compartment size requirementsSmoke compartments and travel distance not compliant
    13 Nov 2014Inspection
    Determined there were deficiencies in abuse/neglect policies, medication order clarifications, and quality assurance oversight.
    • 483.13(c)ABUSE/NEGLECT POLICIES
    • MEDICATION ORDERS/CLARIFICATION
    • QUALITY ASSURANCE/IMPROVEMENT
    05 Aug 2014Inspection
    Investigated an allegation of inadequate bowel elimination care and inadequate hydration; deficiencies were found in bowel protocol implementation and fluid management.
    • Bowel elimination/constipation
    • Bowel protocol
    • Hydration/fluids
    27 Feb 2014Inspection
    Investigated a complaint about care quality and resident safety; identified deficiencies in care practices and documentation.
    10 Dec 2013Life Safety
    Found deficiencies in fire safety features, including inadequate two-hour fire resistance for structural elements and problems with smoke compartments and elevator/stair enclosure fire protection.
    • NFPA 101 Life Safety Code StandardNFPA 101 Life Safety Code Standard
    • NFPA 101 Life Safety Code StandardNFPA 101 Life Safety Code Standard
    27 Nov 2013Inspection
    Investigation found multiple deficiencies related to resident care, including delays in responding to call lights, toileting and pericare, oxygen monitoring, and infection control.
    • Failure to respond to call lights in a timely manner
    • Oxygen saturation monitoring and management
    • Toileting and perineal care/independent transfers
    • Infection control/quality assurance
    27 Feb 2013Inspection
    Investigated a complaint about resident abuse and safety concerns; found failures to document behaviors and implement appropriate care plans and monitoring.
    • Mistreatment, Neglect, and Abusiveness
    23 Oct 2012Life Safety
    Identified several life-safety deficiencies related to fire resistance, enclosure of shafts and stairs, and smoke compartment requirements; some issues were addressed via an evaluation system.
    • NFPA 101 Life Safety Code StandardLIFE SAFETY CODE STANDARD
    • NFPA 101 Life Safety Code StandardLIFE SAFETY CODE STANDARD
    • NFPA 101 Life Safety Code StandardLIFE SAFETY CODE STANDARD
    16 Aug 2012Inspection
    Investigated deficiencies related to care planning and QA for residents with pressure ulcers, including documentation gaps and staff education needs.
    • Continued From page 2
    15 Mar 2012Inspection
    Investigated restraint use and found that several residents were restrained without adequate assessment or documentation, indicating deficiencies in restraint practices and related care planning.
    • 483.13(a)RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS
    09 Jan 2012Life Safety
    Identified deficiencies in life-safety standards related to smoke compartments and travel distance requirements, with a fire safety evaluation used to justify travel distances.
    • NFPA 101 Life Safety Code StandardLIFE SAFETY CODE STANDARD
    • NFPA 101 Life Safety Code StandardLIFE SAFETY CODE STANDARD
    28 Nov 2011Life Safety
    Found multiple life-safety deficiencies related to fire resistance, smoke barriers, and egress that do not meet NFPA 101 Life Safety Code.
    • NFPA 101 LIFE SAFETY CODE STANDARDNFPA 101 LIFE SAFETY CODE STANDARD
    • NFPA 101 LIFE SAFETY CODE STANDARDNFPA 101 LIFE SAFETY CODE STANDARD
    • NFPA 101 LIFE SAFETY CODE STANDARDNFPA 101 LIFE SAFETY CODE STANDARD
    • NFPA 101 LIFE SAFETY CODE STANDARDNFPA 101 LIFE SAFETY CODE STANDARD
    03 May 2011Life Safety
    Identified life-safety code violations involving fire resistance, elevator shaft enclosure, and smoke barrier requirements.
    • NFPA 101 LIFE SAFETY CODE STANDARDLIFE SAFETY CODE STANDARD K012
    • NFPA 101 LIFE SAFETY CODE STANDARDLIFE SAFETY CODE STANDARD K020
    • NFPA 101 LIFE SAFETY CODE STANDARDLIFE SAFETY CODE STANDARD K024
    17 Mar 2011Inspection
    Found deficiencies in dignity and respect, provision of social services, and resident safety/monitoring, with issues related to privacy, wandering risks, and care planning.
    • DIGNITY AND RESPECT OF INDIVIDUALITY
    • PROVISION OF MEDICALLY RELATED SOCIAL SERVICES
    • RECORDS, MONITORING, AND SAFETY-RELATED CARE
    02 Mar 2011Life Safety
    Found several life-safety deficiencies including inadequate two-hour fire resistance for structural elements, noncompliant smoke barriers and travel distances, and missing fire alarm annunciation equipment.
    • NFPA 101 Life Safety Code StandardBuilding construction/Fire resistance
    • NFPA 101 Life Safety Code StandardSmoke barrier travel distance
    • NFPA 101 Life Safety Code StandardSmoke compartment size/travel distance
    • NFPA 72 National Fire Alarm CodeFire alarm annunciation panel
    06 May 2010Inspection
    Investigated a provider and found multiple deficiencies in resident rights, privacy, safety, and care planning. Several resident incidents were documented.
    • Rights and advance directives
    • Privacy and physician contact information
    • Resident safety – falls
    • Care planning (safety and protections)
    • Nutritional/feeding equipment and utensils
    • Resident safety – continued observations
    • Resident Assessments and social services
    06 May 2010Inspection
    Identified deficiencies related to inadequate hydration and insufficient staff training in feeding and care procedures, resulting in dehydration risks for residents and gaps in care planning.
    11 Mar 2010Life Safety
    Identified multiple life-safety deficiencies related to building construction, fire resistance, and smoke barrier travel distances. Noted improper enclosure of elevator spaces and defective door/gasket practices.
    • 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1Building construction type and height / Life Safety Code
    • NFPA 101 Life Safety Code Standard – Elevator and stair enclosure requirements
    • 19.3.7.1Travel distance and smoke compartment size – Life Safety Code

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