Inspection·April 25, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review, staff interview and policy review, the facility failed to ensure an Advanced Directive was signed by the physician. This affected one resident (#67) of one resident reviewed for Advanced Directives of 18 sampled. The facility identified 33 residents who had an Advanced Directive. The facility census was 79. Findings included: Review of the medical record for Resident #67 revealed an admission dated of [DATE]. Diagnoses included Alzheimer's Disease, heart failure, renal failure, and malnutrition. Review of the physician orders dated [DATE] revealed Resident #67 was a Do Not Resuscitate Comfort Care (DNRCC). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #67 was moderately cognitively impaired. Review of the advanced directive for Resident #67 revealed the directive was a DNRCC and the paperwork had not been signed or dated by the physician. Interview with the Registered Nurse (RN) #100 on [DATE] at 11:15 A.M., verified the advanced directive wasn't signed and should have been. Review of the policy titled DNR undated revealed a Do Not Resuscitate (DNR) order means a directive issued by the physician which states a resident should not receive Cardiopulmonary Resuscitation (CPR). For residents without capacity the resident's attending physician has consulted with the resident's hierarchy in descending order of priority, and has fully and frankly discussed with the individual or individuals of priority class of nature of the resident's illness, the resident's treatment options and the potential benefits and reasonably known medical risks, and the majority of initials in the priority class have given written consent and the physician's DNR order. Such consent must also be documented in the medical record of the resident. A DNR Identification Form will be completed by the physician and signed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 2 of 20 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 04/25/2022 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 - Few 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 and resident interview, observation and policy review, the facility failed to ensure care plans were updated. This affected two residents (#18 and #46) of 18 residents reviewed for care plans. The facility census was 79. Findings include: 1. Review of the medical record for Resident #18 revealed an initial admission date of 08/09/21 and a re-admission date of 08/13/21. Diagnoses included Dementia without behavioral disturbance, Chronic Obstructive Pulmonary Disease (COPD), and the need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident #18 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 12 out of 15 (moderate impairment). Her behaviors included disorganized thinking and rejection of care. The resident required extensive assistance of one to two staff members for bed mobility, transfers, locomotion on and off the unit, dressing, personal hygiene, and toilet use. Further review of the MDS revealed the resident's special treatment did not include oxygen therapy. Review of the plan of care dated 03/09/22 revealed the resident used oxygen therapy related to noted decreased oxygen saturation. Interventions included two liters per minute via nasal cannula as ordered. Observations on 04/18/22 at 8:25 P.M. and at 8:41 P.M. revealed Resident #18 did not have Oxygen in place nor did she have a concentrator in her room. Interview on 04/20/22 at 11:26 A.M., with the Director of Nursing (DON) revealed she was unable to find an order for Resident #18 to be administered Oxygen. A follow-up interview on 04/20/22 at 12:08 P.M., with the DON verified Resident #18 did not have an order for oxygen or a concentrator in her room and her care plan must not have been updated to reflect the discontinued oxygen. Review of the facility policy titled, Person-Centered Care Planning Policy and Procedure revised 11/27/17 revealed care plans were to be updated with changes, at least quarterly, and after assessments. 2. Review of Resident #46's medical record revealed an admission date of 02/11/22. Diagnosis included stroke with right dominant hand weakness, expressive aphasia, type two diabetes, and hyponatremia. Review of the physician orders dated April 2022 revealed Resident #46 was ordered a mechanical soft diet due to he was an aspiration risk. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #46 required supervision to eat meals. The quarterly MDS dated [DATE] revealed Resident #46 required limited assistance of one staff member for eating meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 3 of 20 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 04/25/2022 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 - Few Review of the comprehensive plan of care dated 02/18/22 revealed Resident #46 had interventions that included diet as ordered and he required assistance at meals. Review of the Speech Therapy Discharge summary dated [DATE] for Resident #46 revealed a recommendation to have 24-hour care, mechanical soft diet, supervision during oral intake to ensure upright posture during meals and for at least 30 minutes after. It also revealed recommendations for staff to assist Resident #46 with proper swallow techniques. Observation on 04/19/22 at 10:08 A.M. Resident #46's breakfast plate had a hashbrown and ground up sausage. Resident #46 was eating a snickers candy bar with is left hand. Interview on 04/19/22 at 10:08 A.M., Resident #46 revealed he was not interested in his meal. Resident #46 stated he does not like what they served then pointed to his plate and stated, I won't eat that. Observation on 04/20/22 at 08:31 A.M. Resident #46 revealed he had not eaten his breakfast. Resident #46's breakfast plate contained scrambled eggs and gravy sausage. Resident #46's nightstand and bedside table revealed he had an orange, banana, bag of grapes, bags candy, and other snacks. Observation on 04/20/22 08:35 A.M. the Medical Records Staff #839 collected the uneaten breakfast tray from resident #46. The Medical Records Staff #839 had not offered to assist Resident #46 with his meal. At 08:43 A.M., Medical Records Staff #839 brought corn flakes to Resident #46 but did not offer to assist him to eat the cereal. Interview on 04/20/22 at 08:57 A.M., with the Licensed Practical Nurse (LPN) #833 stated Resident #46 sometimes needed help with eating and was unsure what type of diet he was ordered. Observation on 04/20/22 at 12:07 P.M. of the lunch meal State Tested Nursing Assistant (STNA) #828 approached Resident #46 to take away his uneaten lunch meal. STNA #828 had not offered to assist him with his meal, encourage him to eat, or offer an alternative. Interview on 04/20/22 at 2:27 P.M., the Director of Nursing (DON) verified Resident #46's family brings in the fruits, candy, and snacks. The DON verified the family brought in extra snacks and his plan of care had not been followed or updated per speech recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 4 of 20 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 04/25/2022 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 Based on medical record review, staff interview, and review of the hospice agreement the facility failed to ensure residents who received hospice had current detailed and completed hospice medical records. This affected one resident (#25) of two residents reviewed for hospice services. The facility census was 79. Residents Affected - Few Findings include: Review of the medical record for Resident #25 revealed an admission date of 01/17/20. Diagnoses included vascular dementia without behavioral disturbance, Scoliosis, chronic pain, anemia, underweight, body mass index (BMI) 19.9 or less, bilateral unspecified hearing loss, age-related osteoporosis without current pathological fracture, bilateral primary osteoarthritis of the knee, dysphagia oropharyngeal phase, and presence of left artificial hip joint. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/22/22, revealed the Resident #25 had impaired cognition. There were no documented behaviors. The resident required limited assistance of one staff member for eating and extensive assistance of one staff member for all other activities of daily living (ADL). Further review of the MDS revealed the resident received oxygen therapy and hospice services. Review of the plan of care dated 03/03/22 revealed the Resident #25 had a terminal prognosis related to vascular dementia. Interventions included hospice State Tested Nursing Assistant (STNA) twice a week for nine weeks, a hospice social services was to visit once or twice a month for two months, and a hospice nurse was to visit four to five times per month for two months. Review of the hospice notes for the previous three months revealed the notes were dated 04/19/22 and at the top of the page revealed the notes were faxed from the hospice service provider on 04/19/22. Interview on 04/20/22 at 10:09 A.M., with the Director of Nursing (DON) verified the facility had not kept the hospice notes onsite and the hospice notes were faxed to the facility upon request and were sent to the facility after surveyor intervention. Review of the Hospice and facility agreement dated 04/10/15 revealed the facility was to prepare and maintain complete and detailed medical records concerning each hospice resident receiving facility services. The records were to be prepared in accordance with prudent and accepted principles for medical record-keeping procedures and as required by applicable federal and state laws and regulations and Medicare and Medicaid program guidelines. The facility was to retain such records for a minimum of six years from the date of discharge of each Hospice resident or such other time period as required by applicable federal and state law. Each clinical record was to be complete, prompt, accurate, and document all services provided to and event concerning each hospice resident, including evaluations, treatments, progress notes, authorizations to admission to Hospice and/or facility, physician orders, and discharge summaries. Each record was to document that the specified services were furnished and were to be readily accessible and systemically organized to facilitate retrieval by either party. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 5 of 20 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 04/25/2022 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, observation, and policy review the facility failed to perform incontinence care per the facility policy/procedure. This affected two residents (#18 and #50) of three residents reviewed for incontinence care. The facility census was 79. Findings include: 1. Review of the medical record for Resident #18 revealed an initial admission date of 08/09/21 and a re-admission date of 08/13/21. Diagnoses included dementia without behavioral disturbance, Chronic Obstructive Pulmonary Disease (COPD), and the need for assistance with personal care. Review of the bowel and bladder assessment dated [DATE], 11/08/21, and 03/25/22 revealed the resident was able to feel the urge sensation for a bowel movement but was incontinent of bladder and bowel. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/28/22, revealed the Resident #18 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 12 out of 15 (moderate impairment). Her behaviors included disorganized thinking and rejection of care. The resident required extensive assistance of one to two staff members for bed mobility, transfers, locomotion on and off the unit, dressing, personal hygiene, and toilet use. She was frequently incontinent of bowel and bladder and did not have a toileting program. Review of the plan of care dated 03/09/22 revealed Resident #18 had an activities of daily living (ADL) self-care performance deficit related to weakness, status post an acute hospitalization related to acute cystitis, metabolic encephalopathy, recent history of fall with a pubic fracture, distal radius fracture, and status post fall with subdural hematoma (SDH). Interventions included one to two staff assistance to help with toilet use. Review of the plan of care dated 03/09/22 revealed the resident had episodes of urinary incontinence, was at risk for complications related to urinary incontinence including skin breakdown, urinary tract infection, and loss of dignity. Interventions included check and change as required for incontinence, wash, rinse and dry the perineum. Observation and interview on 04/18/22 at 8:25 P.M. Resident #18 stated I'm wet and pushed the call button. Observation on 04/18/22 at 8:41 P.M. with State Tested Nursing Assistant (STNA) #843 revealed no hand hygiene was preformed prior to providing incontinence care for Resident #18. The STNA #843 wet a hand towel that was used to clean the resident peri area. During incontinence care STNA #843 placed the soiled depend and towel used to clean the resident, on the matt next to her bed. Further observation revealed the resident's buttock was not cleansed after being incontinent of urine and before placing a new depend on the resident. There were no trash bags in the resident's room, so the STNA placed the soiled depend and the towel on the floor in the bathroom after looking in the bath room for the trash bags. The STNA removed her gloves by folding them inside out and grabbed the soiled towel and depend with her bare thumb. She then placed the towel and soiled depend back on the floor in the bathroom, wiped her hand on her scrub top, and proceeded out of the room to get the trash bags. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 6 of 20 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 04/25/2022 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few There was no hand hygiene preformed prior to exiting the room or reentering the room after she obtained the trash bags. Interview on 04/18/22 at 8:50 P.M. with STNA #843 verified no hand hygiene was completed prior to the incontinence care, she touched the soiled towel with her bare thumb, no hand hygiene was preformed after touching the towel, and no hand hygiene was performed before exiting the resident's room to get trash bags and reentering the resident's room. Review of the facility policy titled, Perineal Care undated revealed the staff were to wash their hand before and after the procedure. Further review of the procedure revealed the bedside stand or overbed table was to be disinfected and supplies were to be placed on the table. Supplies for the procedure included a basin, filled halfway with warm water. Cleansing of the perineal area included washing from front to back, rinsing the area thoroughly using clean wash clothes, and patting the area dry. Further review of the policy revealed the resident's bony prominence and friction areas were to be checked for redness and/or irritation and the bed was to be checked to ensure the bed linen was clean, dry, and free of wrinkles. Further review of the procedure revealed disposable gloves were to be removed, discarded, and hands were to be washed before exiting the resident's room and disposing of the trash and soiled linen. Review of the facility policy titled, Handwashing Policy dated 11/24/17 revealed hand hygiene was to be performed before and after direct contact with residents and after removing gloves. 2. Review of the medical record for Resident #50 revealed an admission date of 03/24/21. Diagnoses included metabolic encephalopathy, Dementia without behavioral disturbance, type II Diabetes Mellitus (DM2), Chronic Obstructive Pulmonary Disease (COPD), Parkinson's Disease, and Sleep Apnea. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 12 out of 15 (moderate impairment) and no documented behaviors. The resident required supervision and set up for bed mobility, personal hygiene, toilet use, and transfers. He was always continent of bowel and bladder. Review of the care plan dated 02/08/22 revealed the resident was at risk for an alteration to skin integrity related to fecal incontinence, generalized weakness, impaired mobility, positive pressure risk assessment, potential medication side effects, presence of fragile skin, requiring assistance with activities of daily living (ADL) tasks, and urinary incontinence. Interventions included keeping the skin clean and dry. The plan identified bowel and bladder incontinence related to dementia. Interventions included incontinence care every two hours and as needed which included washing, rinse, and dry the perineum as needed. Observation on 04/19/22 at 9:52 AM with State Tested Nursing Assistant (STNA) #828 revealed no hand hygiene was performed before beginning incontinence care for Resident #50. STNA #828 used the same area of the wash cloth for several passes. STNA #828 then cleansed the resident's anus and did not rinse nor dry the resident perineal area. No hand hygiene or glove changes were completed before or after applying the barrier cream or before applying a new depend. The resident's urine soaked pad was placed directly on floor, next to the resident's bed. The STNA #828 adjusted her N95 mask and glasses various times throughout the process with her contaminated and gloved hands. She then exited the room without performing hand hygiene to throw away the trash, dispose of the soiled linen, and get new linen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 7 of 20 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 04/25/2022 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/19/22 at 10:09 A.M., with STNA #828 verified the observations and incontinence care was not preformed per the facility policy. Review of the facility policy titled, Perineal Care undated revealed the staff were to wash their hand before and after the procedure. Further review of the procedure revealed the bedside stand or overbed table was to be disinfected and supplies were to be placed on the table. Supplies for the procedure included a basin, filled halfway with warm water. Cleansing of the perineal area included washing from front to back, rinsing the area thoroughly using clean wash clothes, and patting the area dry. Further review of the policy revealed the resident's bony prominence and friction areas were to be checked for redness and/or irritation and the bed was to be checked to ensure the bed linen was clean, dry, and free of wrinkles. Further review of the procedure revealed disposable gloves were to be removed, discarded, and hands were to be washed before exiting the resident's room and disposing of the trash and soiled linen. Review of the facility policy titled, Handwashing Policy dated 11/24/17 revealed hand hygiene was to be performed before and after direct contact with residents and after removing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 8 of 20 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 04/25/2022 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 and resident interview, observation and policy review, the facility failed to administer oxygen per orders and failed to properly store oxygen tubing/masks. This affected three residents (#25, #35 and #50) of 10 residents who used oxygen in the facility. The facility census was 79. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 01/17/20. Diagnoses included vascular dementia without behavioral disturbance, Scoliosis, chronic pain, anemia, underweight, body mass index (BMI) 19.9 or less, bilateral unspecified hearing loss, age-related osteoporosis without current pathological fracture, bilateral primary osteoarthritis of the knee and presence of left artificial hip joint. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident #25 had impaired cognition. There were no documented behaviors. The resident required limited assistance of one staff member for eating and extensive assistance of one staff member for all other activities of daily living (ADL). Further review of the MDS revealed the resident received oxygen therapy and hospice services. Review of the plan of care dated 03/03/22 revealed the resident used oxygen therapy related to ineffective gas exchange. Interventions included oxygen settings at two liters. Review of physician orders for April 2022 identified an order dated 03/17/22 for oxygen administered at two liters per minute (L/min). Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for March 2022 and April 2022 revealed oxygen at two L/min every shift. Oxygen use was signed off every day of March 2022 starting on 03/18/22 through April including 04/19/22. Observation and interview on 04/18/22 at 7:37 P.M., and 04/19/22 at 9:24 A.M., of Resident #25 revealed she had an oxygen concentrator at the end of her bed and it was not turned on and was not connected to the resident. The resident was unable to recall if she wore oxygen. Observation and interview on 04/19/22 at 11:48 A.M., with Licensed Practical Nurse (LPN) #780 verified Resident #25 was ordered on two liters of oxygen routinely and the resident did not have it in place. 2. Review of the medical record for Resident #35 revealed an initial admission date of 05/19/21 and a re-admission date of 07/23/21. Diagnoses included acute and chronic respiratory failure with hypoxia and hypercapnia, metabolic encephalopathy, Chronic Obstructive Pulmonary Disease (COPD), chronic congestive heart failure (CHF), and malaise. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident #35 had intact cognition and no documented behaviors. The resident required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. She received oxygen therapy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 9 of 20 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 04/25/2022 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the plan of care dated 03/10/22 revealed the resident used oxygen therapy related to CHF, COPD, and acute on chronic respiratory failure. Interventions included Oxygen to be administered at two liters per minute. The plan of care dated 03/10/22 revealed the resident had COPD. Interventions included Oxygen as ordered by the physician. Review of the physician orders for April 2022 revealed an order dated 11/15/21 the Resident #35 had an unclarified amount of oxygen. Review of the physician orders for April 2022 revealed an order for a continuous positive airway pressure (CPAP) machine to be worn nightly. Observation and interview on 04/18/22 at 7:46 P.M., with Resident #35 revealed she was on three liters (L) of oxygen per nasal cannula. The resident stated she was supposed to be on two L. Further observation revealed the residents CPAP mask was stored on top of her machine next to her bed on the nightstand. The resident verified staff store her CPAP mask on top of her machine each day when she removed it from the night use. Observation and interview on 04/19/22 at 11:42 A.M., with LPN #780 verified Resident #35 was to be on an unknown amount of oxygen since her order was blank. She verified Resident #35 was receiving 3.5 L of oxygen per minute and her CPAP mask was stored on the top her machine. Interview on 04/19/22 at 6:05 P.M., with the Director of Nursing (DON) revealed the facility did not have an oxygen tubing storage policy but she did not deny tubing/masks were to be stored in a bag to prevent contamination. 3. Review of the medical record for Resident #50 revealed an admission date of 03/24/21. Diagnoses included metabolic encephalopathy, Dementia without behavioral disturbance, type II Diabetes Mellitus (DM2), Chronic Obstructive Pulmonary Disease (COPD), Parkinson's Disease, and Sleep Apnea. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired) cognition with a Brief Interview of Mental Status (BIMS) score of 12 out of 15 (moderate impairment) and no documented behaviors. The resident required supervision and set up for bed mobility, personal hygiene, toilet use, and transfers, extensive assistance of one staff member for dressing, and he required total dependence for eating. Further review of the MDS revealed the resident was not on oxygen therapy. Review of the physician orders for April 2022 identified an order dated 11/16/21 for CPAP machine settings of plus 11 centimeter of water via nasal mask every night at bedtime and as needed. A physician order dated 04/01/22 revealed Resident #50 had orders for four liters of oxygen and an order dated 04/02/21 to wean oxygen to keep saturation above 90% every shift. Review of the plan of care dated 02/08/22 revealed the Resident #50 used oxygen therapy. Interventions included oxygen at five liters per minute per nasal cannula. Observation and interview on 04/18/22 at 8:27 P.M., with Resident #50 revealed oxygen was in place via nasal cannula at two L/min. The resident's CPAP and nebulizer masks were laying exposed on night stand. The resident said his masks were stored on the table by staffing and he was unable to recall how much oxygen he was supposed to receive. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 10 of 20 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 04/25/2022 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and interview on 04/19/22 at 11:40 A.M., with LPN #780 verified Resident #50 was ordered on four liters of oxygen per minute and he was receiving 2.5 liters and his masks was not stored in a dated bag per the facility policy. Interview on 04/19/22 at 6:05 P.M., with the DON revealed the facility did not have an oxygen tubing storage policy but she did not deny tubing/masks were to be stored in a bag to prevent contamination. Review of the facility policy titled, Oxygen Storage and Therapy revised 01/2018 revealed oxygen was to be administered to residents based on physician order. The policy revealed oxygen liter flow was to be adjusted per physician order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 11 of 20 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 04/25/2022 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident #34 revealed an admission date of 06/01/21, with diagnoses including type two diabetes mellitus with diabetic neuropathy, vascular dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident #34 had severe cognitive impairment and required extensive assistance with all Activities of Daily Living (ADL). Review of the pharmacy recommendations for Resident #34 dated 10/25/21 revealed a recommendation the residents prescribed Methocarbamol (muscle relaxant) 500 milligrams (mg) administered three times daily, be decreased to administered twice daily. The recommendation indicated the decrease in the frequency of the Methocarbamol should be tapered over two to four weeks (11/01/21 through 11/22/21) with the end goal of discontinuation. Review of Resident #34's discontinued medications revealed Resident #34's prescribed Methocarbamol 500 mg was ordered and decreased to twice daily on 12/28/21, five weeks past the recommended date of 11/01/21 through 11/22/21 and discontinued on 04/16/22 approximately five months past the pharmacy recommendation. Interview on 04/20/22 at 10:30 A.M., the DON verified the physician visits the facility twice weekly and Resident #34's pharmacy recommendations were not initiated in a timely manner. Review of the facility policy titled Medication Regimen Review, revised 03/03/20. Procedure 11. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable. Based on medical record review, staff interview, observation, review of the pharmacy recommendations, review of an email correspondence and policy review the facility failed to timely address pharmacy recommendations. This affected two residents (#35 and #34) of five residents reviewed for unnecessary medications. The facility census was 79. Findings include: 1. Review of the medical record for Resident #35 revealed an initial admission date of 05/19/21 and a re-admission date of 07/23/21. Diagnoses included acute and chronic respiratory failure with hypoxia and hypercapnia, metabolic encephalopathy, Chronic Obstructive Pulmonary Disease (COPD), chronic congestive heart failure (CHF), overactive bladder, major depressive disorder, spina bifida, type II Diabetes Mellitus (DM2), Stage III Chronic Kidney Disease (CKD III), hyperlipidemia, iron deficiency anemia, restless legs syndrome, fibromyalgia, hypothyroidism, gastro-esophageal reflux disease (GERD), chronic pain syndrome, history of transient ischemic attack (TIA) and cerebral infarction without residual deficits, muscle weakness, unsteadiness on her feet, and malaise. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/10/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 14 out of 15 (no impairment) and no documented behaviors. The resident required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. She required set up and supervision (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 12 of 20 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 04/25/2022 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for eating. She was frequently incontinent of bowel and bladder. She received oxygen therapy, antipsychotic, antianxiety, opioids, and antidepressant medications. Further review of the MDS revealed the last attempted gradual dose reduction was on 08/24/21 and the physician documented the GDR was clinically contraindicated on 10/14/21. Review of the pharmacy recommendations dated 07/26/21 revealed a recommendation for Resident #35 to stop taking varenicline (smoking cessation) 0.5 milligram (mg). The report revealed the physician declined the recommendations stating the Resident #35 would benefit from continuing varenicline 0.5 mg daily for smoking cessation. Review of the discontinued physician orders revealed varenicline 0.5 mg daily for smoking cessation was discontinued almost a month after receiving the pharmacy recommendation, on 8/24/2021. Review of the pharmacy recommendations dated 11/29/21 revealed a recommendation for a gradual dose reduction (GDR) for buspar (anti anxiety medication). The report revealed the physician agreed with the recommendation and an order to decrease Resident #35's buspar was written on 01/29/22, two months after receiving the recommendation. Review of the pharmacy recommendations dated 01/18/22 recommended a decrease in fingerstick blood glucose testing from twice weekly since her hemoglobin A1C was in a target range. The physician agreed on 03/29/22 over two months after receiving the pharmacy recommendation. Review of the discontinued physician orders revealed the resident finger stick glucose check was discontinued on 03/30/22. Review of the plan of care dated 03/10/22 revealed the resident had or had the potential for pain related to neuropathy, fibromyalgia, spina bifida, stated there was no pain relief from any intervention except medications, and a new onset of knee pain. Interventions included medications as ordered, monitor for effectiveness, assess causes of pain, assist with mobility as needed, assess and/or ask about her pain every shift, and position for comfort. Review of the plan of care dated 03/10/22 revealed the resident had diabetes mellitus. Interventions included monitoring of the resident's glucose per orders and monitoring and updating the doctor as needed. Review of the plan of care dated 03/10/22 revealed the resident used anti-anxiety medications for management of depression/anxiety. Interventions included gradual dose reductions (GDR) attempts as clinically indicated, administration of medications as ordered, and monitor/report side effects. Interview on 04/20/22 at 2:25 P.M., with the Director of Nursing (DON) verified several of Resident #35's pharmacy recommendations were undated, and some were signed by the physician months after the recommendation was dated. Review of the email correspondence dated 04/21/22 at 9:32 A.M. and 9:49 A.M. from the DON revealed the physician came in twice a week. There was also a Nurse Practitioner (NP) and a Physician Assistant (PA) that came into the facility once a week until the month prior to the survey. Review of the facility policy titled, LTC Facility's Pharmacy Services and Procedures Manual revised 03/03/20 revealed the attending physician should address the consultant pharmacists recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 13 of 20 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 04/25/2022 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. 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 and resident interview, observation and policy review the facility failed to ensure residents were provided physician ordered adaptive devices for eating. This affected two residents (#25 and #58) two residents reviewed for devices of 18 residents reviewed. The facility census was 79. Residents Affected - Few Findings include: 1. Review of Resident #58's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included Parkinson's Disease, dementia with behavioral disturbances, bipolar disorder, major depressive and anxiety disorders, lobular carcinoma in the left breast, abnormality of gait, need for assistance with personal care, history of falls, and muscle weakness. Review of the quarterly Minimal Data Set (MDS) dated [DATE] revealed Resident #58 was cognitively intact. She required extensive one to two person assistance for all activities of daily living (ADL) except eating and she was supervision, set up help only. Review of the care plan dated 04/09/22 revealed a plan in place for an ADL care performance deficit related to effects of Parkinson's, acute hospitalization, weakness, impaired balance, mood disorder, bipolar, left lateral lean, worsens in the evening. Fluctuations in status are likely and noted following radiation treatments. Interventions included required supervision with eating. Review of the physician orders dated 03/04/21 revealed regular texture, regular/thin consistency, built up utensils and scoop plate for all meals. Observation on 04/19/22 at 8:36 A.M. and again at 12:10 P.M. revealed Resident #58 was trying to scoop up her meal by using her utensil and her fingers due to not having a scoop plate. She was given a regular plate for both meals. Interview with Staff #721 on 04/19/22 at 12:10 P.M. verified Resident #58 was given her meals on a regular plate. Review of the facility policy titled Lippincott Nursing Procedures, undated revealed the staff were to verify the practitioners order and gather the appropriate materials before meals. 2. Review of the medical record for Resident #25 revealed an admission date of 01/17/20. Diagnoses included vascular dementia without behavioral disturbance, Scoliosis, chronic pain, anemia, underweight, body mass index (BMI) 19.9 or less, bilateral unspecified hearing loss, age-related osteoporosis without current pathological fracture, bilateral primary osteoarthritis of the knee, history of malignant neoplasm of the breast, adjustment disorder with mixed anxiety and depressed mood, malaise, muscle weakness, unsteadiness on her feet, abnormalities of gait and mobility, dysphagia oropharyngeal phase, and presence of left artificial hip joint. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident #25 had impaired cognition. There were no documented behaviors. The resident required limited assistance of one staff member for eating and extensive assistance of one staff member for all other ADL care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 14 of 20 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 04/25/2022 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 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the plan of care dated 03/03/22 revealed Resident #25 was at nutrition/dehydration risk due to advanced age, comorbidities, vascular dementia, mood issues, pressure ulcer (PU), hospice services in place, body weight 84 pounds on 2/22/21, 87 pounds on 11/21/21, 90 pounds on 8/21/22, and 97 pounds on 2/21/22, and was COVID positive on 9/23/21. Interventions included diet as ordered, monitor intake, and offer substitutions if less than 50% consumed, sippy cup at all meals, supplements and fortified cereal as ordered and monitor/document the resident's acceptance, weights as ordered, and notify the responsible party of the significant changes. Review of the plan of care dated 03/03/22 revealed the resident had an ADL self-care performance deficit related to impaired cognitive processes related to dementia, decreased mobility, increased weakness fluctuations, and/or further decline was likely related to ends stage dementia. Interventions included staff assistance to eat. Review of the physician orders for April 2022 identified an order dated 02/25/20 for a regular diet, pureed texture, thin consistency, and pleasure foods. There was no order for an assistive device. Observation on 04/19/22 at 5:59 P.M. revealed Resident #25 fed herself, with a small amount of food on her night gown and had a regular cup with a straw. Observation and interview on 04/20/22 at 8:42 A.M. revealed Resident #25 was lying on her right side with her head of the bed barely raised. She had a napkin in her food which was on a divided plate and a sippy cup was present. She said she was unable to reach her food and could not call for help since her call light was on the floor. Review of the residents meal ticket revealed she was to have a sippy cup with all meals. Interview and observation on 04/20/22 at 8:44 A.M. with Licensed Practical Nurse (LPN) #1000 and STNA #735 verified Resident #25 was unable to reach her food and feed herself while on her right side and in the laying position. The resident's spouted cup was dropped on the floor and taken to the kitchen. Observation and Interview on 04/20/22 at 9:08 A.M., revealed the Assistant Director of Nursing (ADON) was standing next to the Resident #25's bed, encouraged the resident to eat, no sippy cup was present. The resident stated please, I'm not eating. The ADON went to get the residents adaptive sippy cup after surveyor intervention. Resident #25 continued to eat with encouragement but when the encouragement stopped, the resident ceased eating. Observation on 04/20/22 at 9:12 A.M. revealed STNA #735 entered Resident #25's room with a cup of water with a straw. STNA #735 verified she brought a cup of water in with a straw at this time. Review of the facility policy titled, Implementation undated revealed the staff was to review the residents medical record for the resident ability to self-feed, assess the resident's neurological status, dentition, and functional status to determine whether oral feeding was appropriate. Further review of the policy revealed the residents head of bed was to be elevated 30 to 45 degrees to ease swallowing and reduce the risk of aspiration. Further review of the policy revealed spouted (sippy) cups were cups with a spout that was to be used to prevent spills and/or burns for residents experiencing tremors or who have unsteady arms and hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 15 of 20 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 04/25/2022 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 0880 Provide and implement an infection prevention and control program. 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, observations, and policy review the facility failed to perform hand hygiene before and after care, failed to wear gloves when handling soiled linen, failed to properly dispose of soiled linens and a soiled adult brief. This affected three residents (#25, #18, and #50) of 18 residents sampled. In addition, the facility failed to ensure isolation precautions were in place for a resident who required contact precaution. This affected one resident (#50) of two residents reviewed for isolation precautions. The facility census was 79. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 01/17/20. Diagnoses included vascular dementia without behavioral disturbance, Scoliosis, chronic pain, anemia, underweight, body mass index (BMI) 19.9 or less, bilateral unspecified hearing loss, age-related osteoporosis without current pathological fracture, bilateral primary osteoarthritis of the knee, and presence of left artificial hip joint. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had impaired cognition. There were no documented behaviors. The resident required limited assistance of one staff member for eating and extensive assistance of one staff member for all other Activities of daily Living (ADL). Review of the plan of care dated 03/03/22 revealed the resident had an ADL self-care performance deficit related to impaired cognitive processes related to dementia, decreased mobility, increased weakness fluctuations, and/or further decline was likely related to ends stage dementia. Interventions included staff assistance with ADL care. Observation on 04/20/22 at 8:44 A.M., with Licensed Practical Nurse (LPN) #1000 and STNA #735 repositioned the resident without performing hand hygiene prior to providing care with their bare hands. Interview on 04/20/22 at 8:51 A.M. with LPN #1000 verified she had not performed hand hygiene before repositioning Resident #25. Interview on 04/20/22 08:52 AM with STNA #725 verified she had not performed hand hygiene before repositioning Resident #25. Review of the facility policy titled, Handwashing Policy dated 11/24/17 revealed hand hygiene was to be performed before and after direct contact with residents and after removing gloves. 2. Review of the medical record for Resident #18 revealed an initial admission date of 08/09/21 and a re-admission date of 08/13/21. Diagnoses included dementia without behavioral disturbance, Chronic Obstructive Pulmonary Disease (COPD), and the need for assistance with personal care. Review of the quarterly MDS assessment dated [DATE] revealed Resident #18 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 12 out of 15 (moderate impairment). Her behaviors included disorganized thinking and rejection of care. The resident required extensive assistance of one to two staff members for bed mobility, transfers, locomotion on and off the unit, dressing, personal hygiene, and toilet use. She was frequently incontinent of bowel and bladder and did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 16 of 20 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 04/25/2022 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 0880 have a toileting program. Level of Harm - Minimal harm or potential for actual harm Review of the plan of care dated 03/09/22 revealed Resident #18 had an ADL self-care performance deficit related to weakness, status post an acute hospitalization related to acute cystitis, metabolic encephalopathy, recent history of fall with a pubic fracture, distal radius fracture, and status post fall with subdural hematoma (SDH). Interventions included one to two staff assistance to help with toileting. The plan of care dated 03/09/22 included the resident had episodes of urinary incontinence, was at risk for complications related to urinary incontinence including skin breakdown, urinary tract infection, and loss of dignity. Interventions included check and change as required for incontinence, wash, rinse, and dry the perineum. Residents Affected - Few Observation on 04/18/22 at 8:41 P.M. with State Tested Nursing Assistant (STNA) #843 revealed no hand hygiene was performed prior to providing incontinence care for Resident #18. During incontinence care STNA #843 placed the soiled depend and the towel used to clean the resident on the mat next to her bed. The resident's buttock was not cleansed after being incontinent of urine and before placing a new depend on the resident. There were no trash bags in the resident's room so the STNA #843 placed the soiled depend and the towel on the floor in the bath room after looking in the bath room for trash bags. The STNA removed her gloves by folding them inside out and grabbing the soiled towel and depend with her bare thumb. STNA #843 placed the towel and the soiled depend back on the floor in the bathroom, wiped her hand on her scrub top, and proceeded out of the room to get trash bags. There was no hand hygiene performed prior to exiting the room or reentering the room after she obtained the trash bags. Interview on 04/18/22 at 8:50 P.M., with STNA #843 verified no hand hygiene was completed prior to the incontinence care, she touched the soiled towel with her bare thumb, no hand hygiene was preformed after touching the towel, and no hand hygiene was performed before exiting the resident's room to get trash bags and reentering the resident's room. Review of the facility policy titled, Perineal Care undated revealed the staff were to wash their hand before and after the procedure. Further review of the procedure revealed the bedside stand or overbed table was to be disinfected and supplies were to be placed on the table. The procedure revealed disposable gloves were to be removed, discarded, and hands were to be washed before exiting the resident's room and disposing of the trash and soiled linen. Review of the facility policy titled, Handwashing Policy dated 11/24/17 revealed hand hygiene was to be performed before and after direct contact with residents and after removing gloves. 3. Review of the medical record for Resident #50 revealed an admission date of 03/24/21. Diagnoses included metabolic encephalopathy, dementia without behavioral disturbance, type II diabetes mellitus, Chronic Obstructive Pulmonary Disease (COPD), Parkinson's Disease, and sleep apnea. Review of the quarterly MDS assessment dated [DATE] revealed the resident had impaired cognition with a BIMS score of 12 out of 15 (moderate impairment) and no documented behaviors. The resident required supervision and set up for bed mobility, personal hygiene, toilet use, and transfers, extensive assistance of one staff member for dressing, and he required total dependence for eating. Review of the physician orders for April revealed the resident was ordered Sulfamethoxazole-trimethoprim (Bactrim DS) for Methicillin-resistant staphylococcus aureus (MRSA) at his peg tube site for 14 days starting on 04/14/22. There was no order or isolation precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 17 of 20 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 04/25/2022 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 04/18/22 at 8:27 P.M. of Resident #50 revealed he was not on isolation precautions. There was no signage outside of his room nor was there an isolation supply cart outside of his room. Observation on 04/19/22 at 11:40 A.M. with LPN #780 of Resident #50 revealed he was not on isolation precautions. There was no signage outside of his room nor was there an isolation supply cart outside of his room. Observation on 04/19/22 at 9:52 A.M. with STNA #828 revealed no hand hygiene was performed before beginning incontinence care for Resident #50. The resident was also not on isolation precautions. The incontinence care revealed the same area of the wash cloth was used for several passes. The STNA #828 cleansed the resident's anus, no hand hygiene or glove change was completed before or after applying the barrier cream or before applying a new depend. The STNA placed her gloved hand that had left over barrier residue on the residents right shoulder to provide turning assistance. Resident #50's urine soaked pad was placed directly on the floor, next to the resident's bed. The STNA #828 adjusted her N95 mask and glasses various times throughout the process with her contaminated and gloved hands. She then exited the room without performing hand hygiene to throw away the trash, dispose of the soiled linen, and get new linen. Interview on 04/19/22 at 10:09 A.M., with STNA #828 verified the observations and said hand hygiene was not preformed per the facility policy. Interview on 04/20/22 at 5:01 P.M., with the Director of Nursing (DON) verified Resident #50 was prescribed Bactrim DS (antibiotic) for Methicillin-resistant staphylococcus aureus (MRSA) at his peg tube site for 14 days starting on 04/14/22. She also verified Resident #50 was not on isolation precautions but should have been on contact precautions. Review of the facility policy titled, Perineal Care undated revealed the staff were to wash their hand before and after the procedure. Cleansing of the perineal area included washing from front to back, rinsing the area thoroughly using clean wash clothes, and patting the area dry. The procedure revealed disposable gloves were to be removed, discarded, and hands were to be washed before exiting the resident's room and disposing of the trash and soiled linen. Review of the facility policy titled, Handwashing Policy dated 11/24/17 revealed hand hygiene was to be performed before and after direct contact with residents and after removing gloves. Review of the facility policy titled, Isolation Precautions Policy revised 06/08/20 revealed contact precautions were used to prevent transmission of infectious organisms spread by direct or indirect contact with the resident or the resident's environment. Isolation was to include a private room or cohort, clean when entering the room, clean gown when entering the residents room, and limited transport to essential purposes and ensure precautions were taken to minimize contamination of environmental surfaces and equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 18 of 20 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 04/25/2022 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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, and policy review the facility failed to offer residents influenza and pneumococcal immunizations. This affected five residents (#17, #29, #78, #330, and #339) of seven residents reviewed for immunizations. The facility census was 79. Residents Affected - Some Findings include: 1. Review of Resident #17's medical record revealed an admission date of 03/18/22. Diagnosis included chronic kidney disease, encephalopathy, and peripheral vascular disease. Further review of Resident #17's medical record revealed no evidence the resident was offered a pneumonia or influenza vaccine. Review of the influenza and pneumonia vaccine section of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] was coded as not assessed. 2. Review of Resident #29's medical record revealed an admission date of 03/02/22. Diagnosis included neoplasm of the colon, acute kidney injury, and intellectual disability. Further review of Resident #29's medical record revealed no evidence the resident was offered a pneumonia or influenza vaccine. Review of the influenza and pneumonia vaccine section of the comprehensive MDS assessment dated [DATE] was coded as not assessed. 3. Review of Resident #78's medical record revealed an admission date of 03/27/22. Diagnosis included atrial fibrillation, arthritis, and dementia. Further review of Resident #78's medical record revealed no evidence the resident was offered an influenza vaccine. Review of the influenza and pneumonia vaccine section of the comprehensive MDS assessment dated [DATE] was coded as not assessed. 4. Review of Resident #330's medical record revealed an admission date of 04/09/22. Diagnosis included right femur fracture, weakness, and fibromyalgia. Further review of Resident #330's medical record revealed no evidence the resident was offered a pneumonia or influenza vaccine. Review of the influenza and pneumonia vaccine section of the comprehensive MDS assessment dated [DATE] was coded as not assessed. 5. Review of Resident #339's medical record revealed an admission date of 04/02/22. Diagnosis included type two diabetes, urinary tract infection, and weakness. Further review of Resident #339's medical record revealed no evidence the resident was offered a pneumonia or influenza vaccine. Review of the influenza and pneumonia vaccine section of the comprehensive MDS assessment dated [DATE] was coded as not assessed. Interview on 04/20/22 at 12:16 P.M., the Director of Nursing (DON) verified Residents #17, #29, #78, #330, and #339 had not received their influenza or pneumonia vaccine. The DON also verified there was no documentation of the vaccine offered or refused in the resident's medical records. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 19 of 20 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 04/25/2022 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy titled, Prevention Strategies for Influenza dated 06/10/21 revealed each resident will be assessed upon admission and every fall for immunization status and will be offered the pneumococcal immunization if it is not contraindicated. The policy also states the Residents' medical records. shall include documentation of the influenza immunization, contraindication, or refusal. Review of the facility policy titled, Pneumococcal Immunization dated 09/21/21 revealed each resident will be assessed upon admission for immunization status and will be offered the pneumococcal immunization if it is not contraindicated. The policy also states the Residents' medical records shall include documentation of the pneumococcal immunization, contraindication, or refusal. Event ID: Facility ID: 365777 If continuation sheet Page 20 of 20