Health inspection·April 10, 2023

F 0689 • Level of Harm - Immediate jeopardy to resident health or safety On [DATE] at approximately 7:30 P.M. to 8:30 P.M., the Interdisciplinary Team (IDT) had an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting including the following team members: Maintenance Director #400, Admissions Director #355, the DON, Administrator, Central Supply #329, and Registered Nurse (RN) #310, and discussed the root cause of the incident and any follow up measures that needed to be implemented. Residents Affected - Few • On [DATE] at 7:45 P.M., the keypad door of the Fast Track Rehabilitation (FTR) was checked and tested by Maintenance Director #400, and the door was noted to be operating properly. • On [DATE] at 9:00 P.M., the DON completed a visual inspection of all current residents with wander guards to ensure they were in place and operational. No issues were identified. • On [DATE], the Administrator educated Admissions Director (AD) #355 on the new Elopement Management Policy changes. • On [DATE], an elopement drill and education were completed by the DON with all STNAs and Nurses, on wandering/elopement, wander guards, responding to door alarms quickly, exit seeking behaviors and checking on new admissions. • On [DATE], the Administrator and the DON met with Medical Director #600 to discuss the root cause analysis findings and the action plan. Medical Director #600 was out of town the previous week. • On [DATE], the DON/designee audited all the residents, and facility identified Resident #13 (newly admitted ) who did not have a wander guard on, and the facility placed one at that time. Audits will continue for at least four weeks related to any new admissions. • On [DATE], the DON/designee will audit all new admissions to ensure elopement assessments are completed, completed accurately, and a plan of care is implemented to address elopement risks as indicated. Audits will continue for all new admissions for at least four weeks. • On [DATE], all working staff (Nursing, Dietary, Housekeeping, Laundry, Business Office, Activities, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 2 of 9 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 04/10/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Spiritual Care, and Therapy) will be re-educated on the Elopement Policy including wandering/elopement, wander guards, responding to door alarms quickly and exit seeking behaviors by [DATE], and all other staff who are vacationing or out of the community will be reeducated by [DATE] and prior to working any shifts. • On [DATE], the DON and Assistant Director of Nursing (ADON) #411 assessed every resident for elopement risk. There were no identified concerns. • On [DATE], all care plans were reviewed and updated for all residents to reflect current interventions by Minimum Data Set (MDS) Licensed Practical Nurses (LPNs) #442 and #550. • On [DATE], the DON and the Administrator were reeducated on elopement practice and policies by Executive Director of Clinical Operations (EDCO) #500. • On [DATE] at approximately 4:30 P.M., the surveyor completed review of the medical records for Residents #04, #13, #16, #29, and #42, identified as elopement risks, and there were no concerns related to actual elopement from the facility, elopement risk assessments were current and accurate, and care plans were initiated and updated with appropriate interventions to prevent elopement. • On [DATE] between 11:35 A.M. and 12:15 P.M., LPNs #330, #333, and #436, and STNAs #314, and #404, and Housekeeping Staff #319, and #445 verified they were educated on the Elopement Policy including wandering/elopement, wander guards, responding to door alarms quickly and exit seeking behaviors. All staff members interviewed were knowledgeable of the content of each education provided by the facility. • The QAPI Committee will monitor the results of the audits and follow-up as needed. Although the Immediate Jeopardy was removed on [DATE], the deficiency remains at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include Review of the medical record for Resident #82 revealed an admission date of [DATE] at 4:15 P.M. The resident had diagnoses including dementia with behavioral disturbance, paroxysmal atrial fibrillation (A-fib), muscle weakness, and essential primary hypertension. Resident #82 was discharged to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 3 of 9 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 04/10/2023 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 hospital on [DATE] at 7:04 P.M. Level of Harm - Immediate jeopardy to resident health or safety Review of the hospital transfer discharge/continuity of care dated [DATE] for Resident #82, revealed the resident required a skilled level of care with a transfer to the facility dated [DATE]. The discharge orders stated Resident #82 was confused, and forgetful with impaired judgement. Further review of the continuity of care revealed Resident #82 had a need for extensive assistance with toileting, transfers, dressing, and limited assistance with eating. Resident #82's primary admitting diagnosis to the hospital was increased confusion. Further review of the hospital's physical therapy notes dated [DATE], revealed upon Resident #82's discharge, a caregiver would need to provide full time supervision for safety and the resident could be unobserved for brief periods of time but could not be left alone. Residents Affected - Few Review of the incident log dated [DATE] at 6:56 P.M., revealed Resident #82 was recorded as a fall incident. Review of the discharge MDS assessment dated [DATE] for Resident #82, revealed the Brief Interview for Mental Status (BIMS) assessment was coded as the resident's memory being ok. Review of the elopement/wandering assessment dated [DATE] for Resident #82 and completed by RN #310, revealed Resident #82 was recorded as a low risk for elopement. Further review of Resident #82's elopement/wandering assessment indicated the resident was not cognitively impaired or had poor decision-making skills. Review of the plan of care dated [DATE] for Resident # 82, revealed the resident was at risk for falls related to impaired mobility, positive Fall Risk Assessment, impaired cognition and safety awareness related to dementia. Resident #82 had a self-care performance deficit related to decreased induration, Alzheimer's disease, dementia, generalized weakness, and post-acute hospitalization. Review of physician orders dated [DATE] for Resident #82, revealed resident may be admitted to the Skilled Nursing Facility (SNF) for skilled level of care with no diagnosis listed. Resident #82 was not ordered to be on the secured unit. Review of the nurse's progress notes dated [DATE] for Resident #82, revealed no documentation regarding the resident's new admission. Further review of the nurse's progress notes dated [DATE] at 6:56 P.M. (entered as a late entry at 8:14 P.M.) revealed, the resident left the community (facility), angry that his wife left him in community. The resident fell in the parking lot, had a small abrasion to the nose and was tender to touch, vital signs stable (VSS) and the resident's temperature was 98.5 degrees Fahrenheit (normal 98.6). The family and the physician were notified, and the resident was sent to the ED for an evaluation. Review of the hospital records dated [DATE] for Resident #82, revealed resident was seen for injuries from a fall after the resident escaped the building and was found wandering down the road. The hospital records indicated the resident fell and hit his face on an unknown object, and it was unknown if resident had any loss of consciousness (LOC). The resident had a laceration on his nose and the resident was admitted with a fractured nose, increased confusion, contusion on his hip, and neck strain. Resident #82 was discharged to another facility's secured memory care unit. Review of [DATE] witness statement by LPN #308, revealed she was sitting with another resident who was wandering around and trying to go into other resident's room. STNA #309 was helping the new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 4 of 9 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 04/10/2023 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 - Immediate jeopardy to resident health or safety admit (Resident #82) into the bed. The witness statement indicated when STNA #309 put Resident #82 to bed they met to discuss the plans for the 6:00 P.M. to 10:00 P.M. hours. The nurse (RN #310) received a phone call that a resident was outside on the road walking. STNAs #307 and #309 ran outside and saw the resident at the top of the hill on the road with traffic getting piled up. The resident was standing at a car that was parked on the side of the road with two ladies. STNAs #307 and #309 helped Resident #82 back to the rehab center, put the resident into a wheelchair and back inside the building. Residents Affected - Few Review of a [DATE] witness statement by STNA #307, revealed she was at the nurse's station sitting down with a different resident who was wandering around in the hallway. STNA #309 was with the new admit (Resident #82) in his room getting the resident settled in. STNA #309 placed Resident #82 in bed and walked to the nurse's station to discuss the plans for the 6:00 P.M. to 10:00 P.M. hours. The nurse (RN #310) received a phone call stating there was a resident outside on road lying down. STNAs #307 and #309 ran outside to look for the resident when they saw a man standing at a car window with traffic starting to pile at the entrance to the facility. STNAs #307 and #309 ran up the hill to get the resident. Resident #82 had blood on his face, was unsteady on his feet, was confused and no shoes, only socks. The lady that stopped her car offered to take the resident back to the building in her car. STNA #307 and Resident #82 got into the car and the lady drove them back to the Fast Track Rehab entrance. The resident was placed into a wheelchair, was assessed by the nurses, and then taken away by ambulance. Review of a [DATE] witness statement by STNA #309, revealed the STNA put Resident #82 to bed after dinner due to agitation. Resident #82 was under three blankets, looked comfortable and content. Approximately 10 to 15 minutes later, a residents family came out to tell us he saw a resident in the road stumbling around and RN #310 noted it could have been one of the cottage residents, but the family said the resident looked confused. STNAs #307 and #309 immediately ran down the hallway to check Resident #82's room but he was not in there. STNAs #307 and #309 ran outside and began searching for the resident. STNAs #307 and #309 saw a man standing by a car with traffic piling up. STNAs #307 and #309 ran closer and saw it was Resident #82. STNAs #307 and #309 spoke with the two ladies who were standing with the resident and one of the ladies offered to give the resident a ride back to the rehab. Resident #82 was transported back to the facility and the resident was sent to the hospital. Review of the IDT note dated [DATE] at 10:14 A.M., revealed the IDT met to discuss the incident as noted. The resident was sent to the hospital for further evaluation and treatment and the team would reassess upon the residents return. Interview on [DATE] at 9:09 A.M. with LPN #305 stated she was working on an adjacent hall on [DATE], when she learned Resident #82 had exited the facility. LPN #305 stated she did not realize she could run that fast. LPN #305 stated Resident #82 was found on Indian Ripple Road with blood coming from the corner of his upper nose. LPN #305 stated the resident and an employee got in one of the cars and rode back to the facility. LPN #305 stated she assessed Resident #82 upon his return and the resident could not give his name and he was unable to give details of how he left the facility. LPN #305 stated the resident continued to repeat that he did not want to be there. LPN #305 stated Resident #82 was sent to the hospital. Interview on [DATE] at 10:00 A.M. with Unit Manager/LPN #344 stated Resident #82 was not in his room after dinner. Observation at that same time with LPN #344, revealed Resident #82's room was located near the exit doors where Resident #82 exited the facility. LPN #344 stated she did not know anything else about the elopement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 5 of 9 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 04/10/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the facilities investigation file on [DATE] at 10:30 A.M. with the DON revealed the file only contained two witness statements. One from STNA #309 and one from LPN #308. When the surveyor questioned the investigation file, the DON stated she had an additional witness statement from STNA #307 and a phone number for a witness (Community Member #02). Interview on [DATE] at 10:30 A.M. with the DON revealed the facility was not aware Resident #82 was ambulatory. The DON verified the hospital transfer orders indicated Resident #82 utilized a cane or walker to assist him with walking. The DON stated the facility completed a Root Cause Analysis (RCA) of the elopement and believed the issue was the staff thought Resident #82 required two-person assistance with activities of daily living and was physically not able to elope from the facility. Review of the camera footage on [DATE] at 11:33 A.M. with the Administrator on her mobile phone, revealed the resident pushed on the exit doors at 6:38 P.M. and walked briskly up the facilities long driveway, climbed over a guard rail divider and the resident was not able to be viewed after that. The Administrator stated Resident #82 did not have shoes on. Interview on [DATE] at 11:43 A.M. with STNA #307, revealed she observed Resident #82 sitting in a chair in his room after he arrived at the facility. STNA #307 stated Resident #82 appeared confused and acted like he was not aware of what was going on. STNA #307 stated another resident's family member called the unit and stated a resident was outside on the road. STNA #307 stated she ran outside and observed five or six cars backed up on Indian Ripple Road. STNA #307 stated Resident #82 was standing near a stopped car along with two women. STNA #307 stated it appeared they were holding Resident #82 up. STNA #307 stated Resident #82 had both hands bracing himself on the car and he was shaking. STNA #307 stated Resident #82 did not have on any shoes and his nose was bleeding. STNA #307 stated she rode in the car with Resident #82 back to the facility and Resident #82 stated he wanted to go home. STNA #307 stated it was cold outside with very light snow flurries. Interview on [DATE] at 12:08 P.M. with the admitting RN #310, revealed she was the manager on duty when Resident #82 was admitted to the facility. RN #310 stated Resident #82 was admitted around 4:15 P.M. because she remembered looking at her watch and telling Resident #82 it was almost dinner time. RN #310 stated another resident's family member called the facility and reported a resident was on Indian Ripple Road. RN #310 revealed she looked out the therapy room windows and saw an elderly man hunched over; however, she could not tell if he had fallen. RN #310 stated she told STNAs #307 and #309, and they ran out of the door and up the driveway to assist the resident. Resident #82 was returned to the facility, assessed, and sent to the hospital. RN #310 stated she saw Resident #82 in his room eating dinner and that is where she thought he was at the time of the incident. Interview on [DATE] at 3:37 P.M with STNA #309, revealed he was aware Resident #82 had a diagnosis of dementia. STNA #309 reported after Resident #82 arrived at the facility, the resident had a disagreement with his spouse because Resident #82 stated he wanted to go home with her, and the resident's spouse told him he could not go home. STNA #309 stated he observed Resident #82 standing at his closet and looking for his coat. STNA #309 stated he managed to talk Resident #82 into lying in the bed to rest. STNA #309 stated around 6:30 P.M. Resident #82's spouse left the facility. STNA #309 stated he knew Resident #82 would attempt to wander because he appeared confused and stated several times he wanted to leave with his wife; however, STNA #309 stated he never expected Resident #82 to leave the facility. STNA #309 stated Resident #82 continued to state he wanted to go home with his wife. STNA #309 stated around 6:40 P.M. another resident's family was on the phone and stated a resident had gotten out of the facility. STNA #309 stated he and STNA #307 went to Resident #82's room and noticed the resident was not in his room. They ran outside and toward the resident when they noticed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 6 of 9 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 04/10/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few four or five cars backed up on Indian Ripple Road. STNA #309 stated he could see two ladies with Resident #82 on Indian Ripple Road. STNA #309 stated Resident #82 was bleeding at the top of his nose and had grass on his face. STNA #309 stated one of the ladies stated they saw Resident #82 fall in the ditch. STNA #309 stated Resident #82 was confused. Interview on [DATE] at 5:07 P.M. with Resident #82's spouse, revealed she arrived at the facility with her husband on [DATE] around 4:30 P.M. Resident #82's spouse stated she brought Resident #82 to the facility by private car because Resident #82 was walking up and down the hallways at the hospital and the therapist worked on getting the resident in and out of the car and he was fine. Resident 82's spouse stated when she arrived at the facility, the resident climbed out of the car and walked into the facility without any assistance from anyone and using his cane. Resident #82's spouse stated they walked through the rehab unit doors and made a right turn onto the unit. Resident #82's spouse stated they were greeted by STNA #309, and they went into Resident #82's room. Resident #82's spouse stated she observed STNA #309 to calm the resident because he continued to state he wanted to leave and wanted to go home. Resident #82's spouse stated she left the facility at around 6:30 P.M. once Resident #82 was in bed and appeared calm. Resident #82's spouse stated she stressed to STNA #309 and RN #310 to keep an eye on him because he was so far away from the nurse's station, and he was a fall risk. Interview on [DATE] at 6:23 A.M. with LPN #308, revealed she arrived at the facility on [DATE] at 6:00 P.M. to relieve RN #310. LPN #308 reported she did not see or talk to Resident #82 prior to the elopement incident. LPN #308 reported another resident's family member walked out of a resident's room and stated her son just left the facility and called her to report a resident was stumbling on Indian Ripple Road. LPN #308 stated she ran to the doors of the therapy room and looked out the window, but she could not see anything. LPN #308 stated she and STNAs #307 and #309 ran outside and to the top of the drive. LPN #308 stated she looked up the driveway and saw cars stopped on Indian Ripple Road and two Citizens were with an elderly man off to the side of the road. LPN #308 stated it was visible that Resident #82 may have broken his nose and his face was bleeding. LPN #308 stated she called 911 and Resident #82 was discharged to the hospital. Attempts to interview Medical Director #600 were made on [DATE] at 8:53 A.M. and no return call was received. A subsequent interview on [DATE] at 10:40 A.M. with STNA #309 confirmed Resident #82 stated several times he wanted to leave and wanted to go home with his spouse. STNA #309 stated he told RN #310 that Resident #82 made the statements that he wanted to go home. A subsequent interview on [DATE] at 10:53 A.M., with RN #310, revealed she was not sure how Resident #82 arrived at the facility on [DATE], but believed Resident #82's spouse may have brought him. RN #310 stated she marked the Elopement/Wandering assessment for Resident #82 as not having cognitive problems and based this decision on how the resident appropriately responded to her questions about wearing glasses or having dentures. RN #310 stated the resident also answered why he was in the hospital correctly. RN #310 stated she did not get a verbal report from the hospital regarding Resident #82's transfer. RN #310 stated she did not have time to read the hospital transfer orders or the hospital paperwork for Resident #82. Attempts to interview Nurse Practitioner (NP) #602 on [DATE] at 11:20 A.M. revealed NP #602 called the surveyor back and left a message that she was on vacation, and she would not be able to provide information on Resident #82 because she had no access. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 7 of 9 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 04/10/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few A subsequent interview on [DATE] at 11:45 A.M. with the DON, revealed she felt the facility could have done a better job at assessing Resident #82 on admission. The DON stated she felt there could be better communication between admissions staff and the nursing staff. The DON stated her expectations when assessing a resident's cognition would include questions about the date or who is the President. The DON stated she would not expect the nursing staff to base a resident's cognition from answers regarding the use of glasses or dentures. The DON stated the doors Resident #82 walked out of do not alarm unless a resident had a wander guard on. The DON stated anyone could just push on the doors and they would open. During record review of additional residents for elopement risks on [DATE] at 11:50 A.M., with the DON, revealed Resident #13 was discovered as being newly admitted to the facility on [DATE] with a diagnosis of dementia and a history of wandering with no wander guard in place. Further review of the medical record for Resident #13 revealed the resident did not have a wander guard in place according to their new facility policy and their plan of action. The DON indicated the facility revised their admission policy to indicate any new resident with a history of dementia would have a wander guard placed until the facility could accurately assess them for elopement risk. The DON verified the facility failed to assess and identify Resident #13's need to have had a wander guard in place due to being newly admitted and having a diagnosis of dementia and a history of wandering. The DON verified the facility placed a wander guard on Resident #13 on [DATE] after the resident's record was reviewed by the surveyor. During a follow up interview on [DATE] at 11:55 A.M. with the Administrator she stated she was unable to pull up and review the video footage of when Resident #82 arrived at the facility, exiting out of the car and walking into the facility. The Administrator stated she was more concerned with how and when Resident #82 left the faciity on [DATE] and that was the only footage she identified. Interview with AD #355 on [DATE] at 1:00 P.M., revealed she is responsible for assessing residents and determining their admission to the facility. AD #355 stated she assessed residents for admission through the hospital's electronic health records (EHR). AD #355 stated she would send an email to the facility care team as soon as she received a resident's discharge orders. AD #355 stated she was surprised to learn of Resident #82's elopement because the hospital notes indicated the resident was a maximum assist of two staff members per the hospital's therapy notes. AD #355 stated she did not know that Resident #82 was able to get out of his spouse's car upon arrival at the facility on [DATE] and walk to his room unassisted. AD #355 stated it was not unusual for the hospital staff to report a resident's family would be transporting a resident. AD #355 stated if a family member transported a resident to the facility, the facility staff would assist the resident out of the car and into the facility. AD #355 stated Medical Director #600 was included in the admission emails and that was how the communication was given to the Medical Director regarding any new admissions to the facility. AD #355 stated there was no prior approval given from the Medical Director prior to a resident admission. Interview on [DATE] at 1:17 P.M. with Community Member #02, revealed she was driving down Indian Ripple Road and witnessed a car pulled off the side of the road and the resident (Resident #82) was standing and holding onto the car of Community Member #01. Community Member #02 stated the resident was wearing pajama pants and no shoes. Community Member #02 stated it was very cold outside and the resident was bleeding from his face, had grass on his face, and what appeared to be the beginning of a black eye. Community Member #02 sated Community Member #01 told her she did not know the resident and wondered if they could sit him in Community Member #02's car because Community Member #01 had a baby in her backseat. Community Member #02 stated Community Member #01 reported when she found the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 8 of 9 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 04/10/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few resident, he was lying on the street and got up when Community Member #01 pulled over. Community Member #02 stated about three to four staff members came running up the hill to assess the resident. Community Member #02 stated a staff member asked if she could drive a staff member and the resident back to the facility. Community Member #02 stated she drove the resident and staff back to the facility. Interview on [DATE] at 3:40 P.M. with Community Member #01 revealed she was driving past the facility on Indian Ripple Road on [DATE] between 6:45 P.M. and 7:00 P.M. and passed the resident (Resident #82) standing partially in the roadway. Community Member #01 stated she turned around at the cemetery and came back down Indian Ripple Road and observed the resident lying partially on the roadway. Community Member #01 stated she parked her car in a way to try and block the road because she was afraid the resident was going to get hit. Community Member #01 stated the resident got up from the road when she returned and braced himself on her car with both hands. Community Member #01 stated it was cold outside and the resident had blood on his nose and the side of his head. Community Member #01 stated Community Member #02 arrived, and they sat the resident in her back seat because he was shaky. Community Member #01 stated she called the facility and told them a resident was in the road. Community Member #01 stated if this was her grandfather or father, she would lose her expletive. Community Member #01 stated several staff members came running up the road. Community Member #01 stated Community Member #02 and another staff member drove the resident back to the facility. Observation and interview on [DATE] at 12:50 P.M. with Environmental Services Director (ESD) #432, revealed the door Resident #82 exited the facility through had a numerical keypad and the code was posted on a piece of paper above the keypad. ESD #432 was observed to push the door open; however, no alarm sounded. The door was a quick release door and did not have an alarm attached when opened. ESD #432 pointed towards a panel on the door frame and indicated that would alarm if a resident was wearing a wander guard. Review of the [DATE] facility policy titled admission Policy, revealed all inquiries go through the Admissions Director. Prospective residents will be admitted based on determinations from the pre-admission screening and financial verification items available at the time of the request for admission. The admission Coordinator will assign the primary physician and on-call practitioner in the Electronic Health Record. When no physician had been selected, the Medical Director would be assigned until a community credentialed physician of the residents' choice had been assigned. Review of the updated facility policy titled, Elopement Policy, dated [DATE], revealed [NAME] Community would maintain both the freedom and safety of our residents. [NAME] Community will identify residents at risk for elopement and the safety and dignity of those residents will be preserved and promoted by using the least restrictive means as is practical to reduce the risk of or prevent elopement from occurring. Any resident with a dementia diagnosis will have a wander guard placed, despite whether the score indicates the need, in order to allow time for the staff to evaluate the resident. Review of the undated facility form titled, Elopement/Wandering Assessment, revealed. the following questions for a risk assessment finding: 1. If you answer yes to any of the above questions two through 10, resident is a high risk. 2. Notify the DON or supervisor and initiate interventions as appropriate (i.e., wander guard, frequent checks, notify all staff, utilize visual barriers, stop signs, and apply safety alarm to person or adaptive devices).[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365777 If continuation sheet Page 9 of 9