Inspection·August 21, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview, medical record review, and policy review, the facility failed to ensure residents received medications as ordered. This affected one (#20) of four residents reviewed for medications. The facility census was 79. Findings include: Review of the medical record for Resident #20 revealed an admission date of 04/11/19. Diagnoses included unspecified Alzheimer's disease, pseudobulbar effect, and unspecified anxiety disorder. Review of Resident #20's physician orders revealed an order dated 08/07/22 for the narcotic pain medication oxycodone five (5) milligrams (mg), to give 2.5 mg by mouth twice daily for knee pain. Review of a progress noted dated 06/30/23 revealed Licensed Practical Nurse (LPN) #23 administered oxycodone 5 mg instead of oxycodone 2.5 mg to Resident #20. Interview on 08/21/23 at 1:59 P.M., LPN #23 verified she had made a medication error on 06/30/23 when she gave Resident #20 a double dose of oxycodone by mistake. LPN #23 stated she thought she was administering Resident #20's 5:00 P.M. dose of oxycodone 2.5 mg and 6:00 P.M. dose of the antianxiety medication Ativan 0.5 mg when, in actuality, she removed the medications from two separate medication cards of oxycodone 2.5 mg tablets. LPN #23 stated she did not notice her mistake until a few hours later when she tried to reconcile the narcotics books and noticed the counts were off. Review of policy titled, General Dose Preparation and Medication Administration, dated 12/01/07, revealed the facility staff should verify that the medication name and dose are correct when compared to the medication order of the medication administration record. This deficiency represents non-compliance investigated under Complaint Number OH00145219. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365777 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 08/21/2023 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)