Inspection·February 28, 2019

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical review, open medical record review, staff interview, review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) guidelines, and facility policy review, the facility failed to timely complete MDS assessments within the required time frame. This affected two residents (#5 and #3) of 20 residents reviewed for MDS accuracy and timeliness of assessments. The facility census was 82. Residents Affected - Few Findings include: 1. Review of medical record for Resident #5 revealed an admission date of 01/27/12 with diagnoses including Alzheimer's, dementia, and hypertension. She passed away at facility on 12/27/18. Review of Resident #5's MDS assessments revealed no discharge MDS was completed. Her last MDS was a quarterly assessment was dated 10/17/18. Review of the MDS 3.0 RAI guidelines revealed the completion date for the death in facility MDS is to be completed seven days after the date of death . Interview on 02/26/19 at 2:29 P.M., with Licensed Practical Nurse (LPN) #320 verified the discharge MDS was not completed for Resident #5 and verified it was 54 days late. She stated the MDS got missed. 2. Review of medical record for Resident #3 revealed an admission date of 10/09/18 with diagnoses including anemia, diabetes mellitus, and hypertension. She was discharged to the hospital on [DATE] and readmitted to facility on 01/25/19. Review of Resident #3's quarterly MDS dated [DATE] was signed as completed by the Registered Nurse (RN) on 01/29/19 which was one day late. Other sections of the MDS was not completed until 02/20/19 which were 23 days late. Review of Resident #3's discharge MDS dated [DATE] revealed it was completed on 02/20/19 and was 18 days late. Review of Resident #3's reentry MDS dated [DATE] was not completed until 02/18/19 and was 17 days late. Review of the MDS 3.0 RAI guidelines revealed the completion date for quarterly MDS is fourteen days after the assessment reference date, the completion date for discharge assessments is fourteen days after discharge date . The completion date for reentry tracking assessments is seven days after the entry date. Interview on 02/26/19 at 2:29 P.M., with LPN #320 verified the MDS's were not completed for Resident #3 timely and said they were behind and trying to play catch up. Review of facilities Resident Assessment and MDS Policy dated 01/18/18, revealed the MDS nurse is responsible for conducting and coordinating each resident assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 2 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) guidelines, and facility policy review, the facility failed to timely submit MDS assessments within the required time frame. This affected one resident (#3) out of six residents reviewed for MDS timeliness of submission. The facility census was 82. Residents Affected - Few Findings include: Review of medical record for Resident #3 revealed an admission date of 10/09/18 with diagnoses including anemia, diabetes mellitus, and hypertension. She was discharged to hospital on [DATE] and readmitted to facility on 01/25/19. Review of Resident #3's quarterly MDS assessment dated [DATE] revealed it was signed as completed by the Registered Nurse (RN) on 01/29/19 and other sections of the MDS were not completed until 02/20/19. The MDS was not yet submitted and per RAI guidelines was to be submitted by 02/12/19. Review of Resident #3's discharge MDS dated [DATE] revealed it was completed on 02/20/19 and not yet submitted. Per RAI guidelines it was to be completed fourteen days after discharge and submitted fourteen days after that date. Interview on 02/26/19 at 2:29 P.M., with Licensed Practical Nurse (LPN) #320 verified the MDS's was not submitted in required timeframe for Resident #3. She revealed they ere behind and trying to play catch up. Interview on 02/26/19 at 2:47 P.M. with the Director of Nursing (DON) revealed she had two LPNs completing the MDS's and she signed them once completed. She was not aware they were running late on being completed and submitted. Review of facilities Resident Assessment and MDS Policy dated 01/18/18 revealed the MDS nurse is responsible for conducting and coordinating each resident assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 3 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0642 Ensure a qualified health professional conducts resident assessments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) guidelines, and facility policy review, the facility failed to ensure the Registered Nurse (RN) coordination of assessments and failed to ensure a RN signed and certified the MDS's were complete. This affected two residents ( #3 and #48) of six residents reviewed for MDS accuracy and RN signature. The facility census was 82. Residents Affected - Few Findings include: 1. Review of medical record for Resident #3 revealed an admission date of 10/09/18 with diagnoses including anemia, diabetes mellitus, and hypertension. Review of quarterly MDS assessment dated [DATE] revealed the latest sections signed as completed by a licensed practical nurse (LPN) was 02/20/19, there were sections of the MDS also signed off by a therapist on 02/15/19 and social services on 02/01/19. The signature of the RN assessment coordinator verified assessment completion was 01/29/19 before sections were completed. 2. Review of medical record for Resident #48 revealed an admission date of 09/30/18 with diagnoses including depression, anxiety, and anemia. Review of quarterly MDS assessment dated [DATE] revealed the latest sections signed as completed by LPN was 12/27/18. The signature of the RN assessment coordinator verifying assessment completion was 12/21/18 before sections were completed. Interview on 02/26/19 at 2:47 P.M., with the Director of Nursing (DON) verified she signs off the MDS once completed. Interview on 02/26/19 at 5:15 P.M., with the DON revealed she had two LPNs who complete MDS's. They set the MDS dates, open them, set the schedule, and then she watches her computer for the in progress section of the MDS. Once they were signed she goes in and signs them. She stated she was not aware when MDS's were late. She verified her signature was before sections of the MDS were completed for Resident #3 and Resident #48 and she did not know how that could have happened. She was unaware she could sign the MDS's if they were not complete. Review of facilities Resident Assessment and MDS Policy dated 01/18/18, revealed a RN must sign and date that the Resident Assessment is accurate and complete. The completed MDS is done by the fourteenth day and or amended with the RN signing that the MDS is complete. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 4 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review. the facility failed to timely revise the plan of care for five residents (#48, #49, #59, #61, and #433) of 18 care plans reviewed. The facility census was 82. Findings include: 1. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, Parkinson's disease, hypertension (HTN), major depression, and functional quadriplegia. Review of the plan of care (POC) target date of 01/28/19 revealed she had problems and goals to include activities of daily living (ADLs), pain, incontinence, skin break down, side effects of antidepressant medications, anticoagulant therapy, diuretic therapy, and HTN. The problems, goals, and interventions had not been updated or revised with the last MDS quarterly assessment. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed she had intact cognition, no mood issues, however one to three days she yelled, screamed or cursed at others. She was totally dependent on staff for all care, and was incontinent of bowel and bladder. Interview on 02/26/19 at 4:30 P.M., with the Director of Nursing (DON) revealed they were behind on many of the care plans and were trying to get caught up. Interview on 02/28/19 at 3:23 P.M., with Licensed Practical Nurse (LPN) #318 revealed she was the MDS nurse and she had not been able to revise and update all the plans. 2. Review of the medical record revealed Resident #433 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia without behavioral disturbances, HTN, chronic kidney disease stage four, and diabetes. Review of the physician order dated 11/13/18 revealed a change in code status from full code to do not resuscitate comfort care (DNRCC). Review of the advanced directive form dated 11/14/18 had the signature of Physician #322. Review of the MDS quarterly assessment dated [DATE] revealed the resident had impaired cognition, he required extensive assistance of two staff for bed mobility, transfer and toileting. Review of the POC dated 01/14/19 revealed Resident #433 was a Full Code and would receive artificial resuscitation in the event of an emergency. Interview on 02/28/19 at 9:27 A.M., with Physician #322 confirmed Resident #433's code status was changed to a DNRCC. Interview on 02/28/19 at 3:23 P.M., with LPN #318 revealed she was unsure why she did not update the POC and should have. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 5 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. Review of medical record for Resident #61 revealed an admission date of 02/05/19 with diagnoses including Alzheimer's, dementia, hypertension, anemia, chronic kidney disease, and edema. Review of Resident #61's care plan revealed she was at a nutritional risk due to decline in condition, medical problems, decreased intake and cognitive loss. There was no update to reflect her weight loss. Review of interventions did not reveal she was on supplements or weekly weights. Review of the quarterly MDS assessment dated [DATE] revealed Resident #61 had severe cognitive loss, no significant weight change and received a therapeutic diet. Review of physician orders dated February 2019 revealed Resident #61 was on a regular diet with no added salt (NAS) and received 2 cal supplement four times a day. Review of monthly weights revealed Resident #61 had a 15.94 % (percent) weight loss in last six months and a 17.39 % weight loss in last 30 days based on weight of 160 pounds on 08/11/18, weight of 162 pounds on 01/07/19 and a weight of 138 pounds on 02/06/19. Review of dietary note dated 02/19/19 revealed Resident #61 had a significant weight loss, meals had been 50% on average. The resident was taking three cans of Glucerna a week and recommended 2 cal supplement four times a day and will monitor weights, intakes, and acceptance of supplement. Interview on 02/28/19 at 10:09 A.M., with the DON verified Resident #61's care plan was not updated to reflect weight loss and updated interventions for weekly weights and supplements. Review of facilities Person-Centered Care Planning Policy dated 11/27/17 revealed the interdisciplinary team shall develop and implement care plans for each resident that includes instructions needed to provide effective and person-centered care of the resident that meets the professional standards of quality care. The care plan includes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well being. 3. Review of medical record for Resident #59 revealed an admission date of 7/14/15 with diagnoses of Alzheimer's disease and major depression. Review of Resident #59's nurse's progress note dated 01/05/19 revealed the resident was verbally aggressive towards staff using foul language. Review of the MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. On 01/23/19 the resident was aggressive during a shower. He was punching, hitting and kicking State Tested Nursing Assistants (STNAs) and refused assistance with his ADLs. Resident #59's physician was notified by LPN #212 and Physician #323 ordered Haloperidol (anti-psychotic) tablet 2 milligrams (mg) one time a day every Wednesday and Saturday, one hour prior to staff giving the resident a shower. Review of the Plan of Care last updated on 1/26/19 for Resident #59 revealed no behaviors of hitting, kicking, biting, or the use of Haloperidol. On 02/27/19 at 10:58 A.M., interview with LPN #212 confirmed Resident #59 was receiving Haloperidol prior to being given a shower twice a week. The LPN revealed the resident resisted showers. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 6 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff tried different approaches to engage the Resident in showering such as low lighting in the shower room, having his spouse assist staff during the showers and nothing was effective until the medication was utilized. Review of the Medication Administration Record (MAR) from 01/26/19 to 2/23/19 revealed Resident #59 received Haloperidol one hour before his shower every Wednesday and Saturday for a total of nine occurrences. On 02/27/19 at 11:30 A.M., interview with the Director of Nursing (DON) revealed Resident #59's POC did not include Resident #59 having any type of behaviors of hitting, kicking, biting, or the use of Haloperidol. 4. Review of the medical record for Resident #48 revealed an admission date of 08/31/18. Diagnoses included displaced intertrochanteric fracture of the right femur, chronic obstructive pulmonary disease, Alzheimer's disease, and history of falls. Review of Resident #48's oral assessment dated [DATE] revealed the resident had upper and lower dentures. There was no answer marked for the questions on whether the dentures fit properly, or if the resident could take them in and out. Review of the quarterly MDS assessment dated [DATE] revealed Resident #48 had moderate cognitive impairment. The resident was noted to not have any broken or ill-fitting dentures. Review of Resident #48's care plan dated 02/18/19 revealed the resident wore upper and lower dentures. The resident was to receive oral care in the A.M. and P.M. The care plan also recommended the resident's upper dentures be removed for meals, while keeping the lower dentures in place. On 02/25/19 at 3:27 P.M. interview and observation of Resident #48 revealed the resident was edentulous (no teeth) and was not wearing any dentures. Resident #48 revealed she had dentures, however had not worn them for a long time because they didn't fit well. She stated she would love to be able to have good fitting dentures. On 02/27/19 at 9:08 A.M., interview with LPN #212 and Social Worker #150 both confirmed the resident did not wear her dentures because they did not fit correctly. Interview on 02/27/19 at 12:57 P.M., with LPN #171 revealed she was the nurse who completed and updated the resident's care plans. LPN #171 confirmed Resident #48's care plan only revealed the resident needed to have her upper dentures removed during meals. She confirmed he resident had ill filling dentures and could not wear them and the POC needed to be updated to reflect the resident's current oral status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 7 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interview, resident interview, and review of assignment sheets, the facility failed to timely implement physician orders. This affected one resident (#75) of 21 resident reviewed for implementing physician orders. The facility census was 82. Residents Affected - Few Findings include: Review of the medical record revealed Resident #75 was admitted to the facility on [DATE]. Diagnoses included acute diastolic heart failure, edema, chronic kidney disease stage three, abnormal weight gain, syncope with collapse, fall with fracture right lower extremity prior to admission, and localized edema. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident had intact cognition, and required extensive assistance of staff for bed mobility, transfer and toileting due to non weight bearing status of the right lower extremity. Review of the physician orders (PO) dated 02/18/19 revealed TED hose (anti-embolism stockings) were to be on Resident #75 in the morning and off in the evening. Review of the plan of care (POC) revised 02/19/19 revealed TED hose were to be on Resident #75 in the morning and off in the evening. Review of the assignment sheet updated 02/22/19 revealed Resident #75's TED hose were not listed as ordered. Observation and interview on 02/25/19 at 10:18 A.M., with Resident #75 revealed the resident was sitting up in the wheelchair in his room with a cast on the right left from the knee down. A family member was at the bed side. His left leg was red, shiny and edematous (swollen). No [NAME] hose were observed on the resident. At 3:30 P.M., Resident #75 was sleeping in his recliner, no TED hose was observed on his left leg. At 5:15 P.M., Resident #75 was in the dining room in his wheelchair and no TED hose was observed on his left leg. Resident #75 revealed he had not had TED hose on since he moved from the rehab hall. Observation on 02/26/19 at 8:28 A.M., revealed Resident #75 was up in his chair and TED hose were not observed on at this time. Observation on 02/27/19 at 8:11 A.M., Resident #75 was sitting in the hallway in his wheelchair with no TED hose on at this time. At 12:30 P.M., Resident #75 was in the dining room and he had no TED hose on his left leg. Interview on 02/27/19 at 12:30 P.M., with Licensed Practical Nurse (LPN) #211 confirmed Resident #75 did not have TED hose on his left leg. She reviewed he should have TED hose placed on the left leg in the morning and removed in the evening. State Tested Nursing Assistant (STNA) #253 revealed she never placed TED hose on Resident #75's left leg because it was not on the assignment sheet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 8 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on medical record review, staff interview, and facility policy review, the facility failed to investigate a resident's fall. This affected one resident (#59) of one resident reviewed for falls. The facility census was 82. Residents Affected - Few Findings include: Review of medical record for Resident #59 revealed an admission date of 7/14/15 with diagnoses including Alzheimer's disease and major depression. Review of the Minimum Data Set (MDS) assessment completed on 01/09/19 revealed the resident had severe cognitive impairment. Review of Resident #59's nurse's progress note dated 01/20/19 revealed at 4:45 A.M., the resident was found on the floor in another resident's room. Resident #59 denied any pain or discomfort. Licensed Practical Nurse (LPN) # 220 assessed Resident #59 and found no injuries. There was no evidence the facility completed a fall investigation of the fall. On 02/27/19 at 4:06 P.M., interview with the Director of Nursing (DON) revealed she received notification by email of Resident #59 being found on the floor of another resident's room. She confirmed the facility did not do an investigation of the fall in accordance with their Accident /Incident policy and procedure Review of the Accident/Incident Policy and Procedures dated 01/10/14 revealed an incident as any event, occurrence, situation or circumstances which may or may not result in bodily injury of a resident. All incidents of any kind, which directly involve a resident including falls, the nurse is to complete the electronic incident report, at a minimum, by the end of his/her shift. The incident follow up will also be completed and an appropriate intervention shall be implemented immediately to prevent the incident reoccurring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 9 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interview, resident interview, and review of the facility policy, the facility failed to ensure ongoing dialysis communication between the dialysis and the facility was maintained for one resident (#27) of one reviewed for dialysis. The facility census was 82. Residents Affected - Few Findings include: Review of the medical record for Resident #27 revealed an admission date of 01/30/19 with a readmission date of 02/13/19. Diagnoses included end stage renal disease (ESRD), dependence on renal dialysis, and type two diabetes. Review of the five-day Minimum Data Set (MDS) assessment from the resident's previous admission, revealed Resident #27 had moderate cognitive impairment. Further review revealed the resident was on hemodialysis. Review of the care plan for Resident #27 dated 02/13/19, revealed the resident utilized hemodialysis related to renal failure. Interventions included but not limited to check and change dressing daily, access site, document assessment of the resident upon return to the facility from dialysis, coordinate care and services as they related to dialysis with the staff at the dialysis center. Do not draw blood or take blood pressure in the graft arm, and labs to be drawn at the dialysis center and reports to be sent to the facility. On 02/26/19 at 4:48 P.M., interview with Registered Nurse (RN) #196 denied receiving any communication for Resident #27 from the dialysis center. She stated the dialysis center never sent any information home with the resident. She said she assumed they would reach out to the facility if there was a need. On 02/27/19 at 8:21 A.M., interview with Licensed Practical Nurse (LPN) #170 revealed Resident #27 took a dialysis information packet with her every time she went to dialysis. On 02/27/19 at 8:25 A.M., an interview with the Director of Nursing (DON) confirmed no documentation of any dialysis communication was noted in the Resident #27's medical record. On 02/27/19 at 8:30 A.M., the DON produced two laboratory results dated [DATE] and 02/20/19 for Resident #27. The DON stated the two lab reports were the only dialysis communication she could find. She verified there was no other communication from the dialysis facility documented in the resident's chart. On 02/27/19 at 11:20 A.M., in an interview with Unit Manager #317 she confirmed the facility's policy was to have the unit manager contact the dialysis facility if no paperwork was returned after a dialysis visit. She also confirmed she had not been notified by the staff of not receiving any post dialysis documentation and she had not contacted the dialysis for any communication paperwork. Review of the facility's policy titled Hemodialysis [NAME] Community dated 07/2015, revealed upon return from the dialysis facility the information packet of notes from the dialysis nurse should be reviewed and process accordingly. It also stated if notes are absent upon the residents return, the charge nurse is to call the dialysis center for the report. In addition, the dialysis center will assure they communicate any labs and/or orders to the home facility. The staff will assure this information returns from dialysis appointments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 10 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interview, and facility policy review, the facility failed to adequately monitor a resident's behaviors who was taking an anti-psychotic medication. This affected one resident (#50) of seven reviewed for unnecessary medications. The facility census was 82. Residents Affected - Few Findings include: Review of the medical record revealed Resident #50 was admitted to the facility on [DATE]. Diagnoses included dementia with behaviors, anxiety, abnormal weight loss, sarcopenia, and Alzheimer's disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had impaired cognition. She had behaviors such as wandering, screaming, smearing bodily wastes, and disrobing. Review of the plan of care dated 02/16/19 revealed Resident #50 had mood problems, anxiety and was resistive to care. The resident would spit into tissues, spit on the floor, resist eating, remove clothing, and was at risk for drowsiness, fatigue and slowed reflexes. Interventions included monitor/document side effects and effectiveness of medications, monitor/record occurrence of target behavior symptoms pulling her own hair, spitting on the floor, and document. Review of the current physician orders revealed Resident #50 had an order for Seroquel (an antipsychotic medication), every eight hours for anxiety and agitation routinely. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for February 2019 revealed the resident was not documented as having any behaviors. Specifically on 02/25/19. Observation on 02/25/19 from 10:15 A.M., to 5:45 P.M., Resident #50 was observed spitting on the floor, wandering throughout the facility, running into other resident's wheelchairs in the dining area. Staff were observed with her one to one. Interview on 02/28/19 at 9:45 A.M., with Physician #322 revealed Resident #50 had behaviors and was very busy around the facility. The physician revealed she expected the nurses to document behaviors in the medical record. Interview on 02/28/19 at 10:01 A.M., with the DON confirmed there was no documentation of Resident #50's behaviors on 02/25/19. Review of the policy titled Behavior Problems Policy revised 06/18 revealed the event should have a full description of what the behavior is, how the resident was doing it, where it occurred, when did it occur, what interventions were attempted and the effectiveness of the interventions and to notify family, physician and the Inter-Disciplinary Team (IDT). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 11 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident's (#63)ordered as needed anti-anxiety medication was reviewed every 14 days. The facility further failed to ensure a resident (#59) who was ordered an anti-psychotic medication had an appropriate diagnoses for the use of the medication. This affected two residents (#63 and #59) of seven reviewed for unnecessary medications. The facility census was 82. Findings include: 1. Review of medical record for Resident #63 revealed admission date of 04/13/17 with diagnoses including adjustment disorder with anxiety, dementia with Lewy bodies, and kidney failure. Review of the most recent Minimum Data Set (MDS) assessment revealed the resident intact cognition. Review of Resident #63's December 2018 physician's orders revealed an order for Ativan, 0.5 milligrams (mg), every 12 hours, as needed for anxiety. Review of the Medication Administration Record (MAR) from 12/12/19 to 2/28/19 revealed Resident #63 received Ativan 18 times. Review of physician's progress notes dated 01/19/19 (37 days after the original order) revealed the physician assessed and documented a reason for the use of Ativan. On 02/28/19, the physician assessed and documented a reason for the use of Ativan. On 02/28/19 at 1:26 P.M.,. interview with Physician #322 confirmed she did not review the use of Ativan as needed for Resident #63 every 14 days. 2. Review of Resident #59's medical record revealed an admission date of 07/14/15 with diagnoses including Alzheimer's disease, and major depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficits. Review of Resident #59's nurse's progress note dated 01/05/19 revealed the resident was verbally aggressive towards staff using foul language. On 01/23/19, the resident was aggressive during a shower. He was punching, hitting, and kicking staff. Resident #59's physician was notified by Licensed Practical Nurse (LPN) #212 and an order was received to give the resident Haloperidol (anti-psychotic) 2 mg, one time a day, every Wednesday and Saturday, one hour prior to staff giving the resident a shower. Review of the MAR from 01/26/19 to 2/23/19 revealed Resident #59 received Haloperidol one hour before his shower every Wednesday and Saturday, for a total of nine times. On 02/27/19 at 10:58 A.M interview with LPN #212 revealed Resident #59 was receiving Haloperidol before his showers. The LPN revealed the resident resists showering. The staff tried different approaches to engage the resident in showering, such as low lighting in the shower room, having his spouse assist staff during the showers and nothing was effective until the medication was utilized. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 12 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm On 02/27/19 at 12:40 P.M., interview with the Director of Nursing (DON) confirmed Resident #59 was receiving Haloperidol prior to being given showers. The DON confirmed the resident did not have a diagnosis to support the used of the Haloperidol. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 13 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, staff interview, and facility policy review, the facility failed to ensure lab test ordered were completed as ordered by the physician. This affected one resident (#433) of one resident reviewed for lab orders. The facility census was 82. Findings include: Review of the closed medical record revealed Resident #433 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia without behavioral disturbances, a mechanical heart valve, chronic kidney disease stage four, and diabetes. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #433 had impaired cognition, and took an anticoagulant (blood thinner) seven days. Review of the plan of care dated 01/14/19 revealed Resident #433 was on anticoagulant therapy and would be free from adverse reactions related to anticoagulant use. Interventions included laboratory values as ordered, monitor for bleeding, and avoid foods high in Vitamin K (a vitamin which caused thicker blood). Review of the physician order dated 01/09/19 revealed the Prothrombin Time and International Normalized Ratio (PT/INR) was reviewed and an order for another PT/INR was ordered to be completed on 01/16/19. There was no evidence the lab was ever drawn. The resident's anticoagulant was ordered to be held on 01/19/19 and to complete another PT/INR on 01/18/19. Review of the lab value of the PT/INR dated 01/18/19 revealed the result to be 54.8/5.7 (the therapeutic range for the mechanical heart valve was 2.5-3.5 seconds it takes for blood to clot). The physician was notified and the medication was ordered to be held. Interview on 02/27/19 at 12:04 P.M., with Licensed Practical Nurse (LPN) #205 revealed she never saw Resident #433 exhibit any signs of bleeding. The LPN confirmed she took the order on 01/09/19 for the follow up PT/INR for 01/16/19, however did not put it into the system. Review of the policy titled Anticoagulation Administration revised 04/2016 documented PT/INR monitored as ordered per the physician and per INR process. Review of the policy titled Laboratory Orders Policy revised 10/2018 documented the charge nurse obtains and notes physician's orders, completes a lab requisition in the computer, the night shift nurse for each unit will print off the daily log and requisitions daily, the night shift nurse will verify all needed labs are on the daily log and add to the log as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 14 of 14