Health inspection·April 3, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to refer residents for Pre-admission Screening and Resident Review (PASARR) level two services after a significant mental health change. This affected one (56) of the six residents reviewed for PASARR. The census was 81. Findings include: Review of the medical record for Resident #56, revealed the resident was admitted to the facility on [DATE]. Her diagnoses included but were not limited to bipolar disorder, psychotic disorder with delusions, and mood disorder. Review of the Brief Interview for Mental Status (BIMS) dated 02/18/25 for Resident #56 revealed a score of 12, indicating the resident was moderately cognitively intact. Review of Resident #56's medical records revealed the following mental health diagnoses were not included in her current PASARR application: bipolar disorder (02/27/25), Mood Disorder (09/06/24), and Psychotic Disorder with Delusions (09/06/24). There was no documented evidence that an initial or significant change PASARR application/form was submitted to the state agency to decide if the resident needed level II services. Interview with the Administrator and Admissions Coordinator #368 on 04/02/2025 at 08:23 A.M. confirmed the facility had no documented evidence they submitted a significant change PASARR application for Resident #56 after new mental health diagnoses. Review of the policy Preadmission Screening and Annual Resident Review (PASARR) dated on 08/12/15 revealed the community will refer all residents with newly evident or possible serious mental disorders for a level II review upon a significant change in status assessment to the state PASARR represented. Page 1 of 7 365777 365777 04/03/2025 Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure baseline care plans were developed within 48 hours of admission. This affected three (#29, #54, and #139) of the 12 residents reviewed for baseline care plans. The facility census was 81. Findings include: 1. Review of the medical record of Resident #29 revealed an admission date of 02/27/25. Diagnoses included acute on chronic congestive heart failure (CHF), acute and chronic respiratory failure with hypoxia and hypercapnia, type 2 diabetes mellitus, morbid obesity, prostate cancer, and hypothyroidism. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #29 had intact cognition. The resident required supervision for eating, and was dependent on staff for toileting, bathing, dressing, bed mobility, and transfers. Review of the care plans revealed a baseline care plan was initiated on 03/11/25. Interview on 04/01/25 at 2:57 P.M., Licensed Practical Nurse (LPN) #417 verified Resident #29 was admitted on [DATE] and a baseline care plan was completed on 03/11/25 and should have been completed within 48 hours of admission. 2. Review of the medical record of Resident #139 revealed an admission date of 03/21/25. Diagnoses included vertigo, type 2 diabetes mellitus, and congestive heart failure. Review of the care plans revealed a baseline care plan was initiated on 03/24/25. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had intact cognition. The resident required substantial/maximal assistance with eating and was dependent for toileting, bathing, dressing, bed mobility, and transfers. Interview on 04/01/25 at 2:57 P.M., LPN #417 verified Resident #139 was admitted on [DATE] and a baseline care plan was not started until 03/24/25. 3. Review of the medical record for Resident #54 revealed an admission date of 02/21/25. Diagnoses included other toxic encephalopathy, sepsis, other acute kidney failure, hypovolemia, hypo-osmolality and hyponatremia, type one diabetes mellitus, dementia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, generalized anxiety disorder, congestive heart failure, and major depressive disorder. Review of the five-day MDS assessment dated [DATE] revealed Resident #54 had severely impaired cognition. Resident #54 was assessed to require supervision for eating, substantial/maximal assistance for oral hygiene, lower body dressing, bed mobility, and transfer, partial/moderate assistance for upper body dressing, and was dependent for toileting. 365777 Page 2 of 7 365777 04/03/2025 Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440

F 0655 Level of Harm - Minimal harm or potential for actual harm Review of the baseline plan of care revealed it was initiated on 02/21/25 but was not completed until 02/24/25. Interview on 04/03/25 at 11:53 A.M. with the Director of Nursing (DON) verified the baseline care plan indicated it was started on 02/21/25 but was not completed until 02/24/25. Residents Affected - Few Review of the facility policy titled, Resident Directed Care Planning, dated 11/22/16, revealed the baseline care plan should be developed within 48 hours of a resident's admission and include the minimum healthcare information necessary to properly care for a resident. A comprehensive care plan can be developed in place of the baseline care plan if it is developed within 48 hours of the resident's admission. 365777 Page 3 of 7 365777 04/03/2025 Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure meal intakes were monitored and recorded. This affected one (#77) of the seven residents reviewed for nutrition. The facility census was 81. Residents Affected - Few Findings include: Review of the medical record for Resident #77, revealed an admission date of 01/16/24. Diagnoses included but were not limited to metabolic encephalopathy, urinary tract infection, and Coronavirus (COVID-19). Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #77 had severe cognition evidenced by a Brief Interview for Mental Status (BIMS) of 00. The resident was dependent on staff for activities of daily living (ADLs). Review of the documentation for Nutrition Amount Eaten from 03/21/25 through 04/02/25 for Resident #77, revealed the dinner time meal intakes were not documented for dinner with the exception of 03/25/2025. Interview on 04/02/25 at 10:30 AM with the Dietician Tech (DT) #345 confirmed Resident #77's dinner intakes were not recorded accurately from 03/21/25 through 04/02/25. 365777 Page 4 of 7 365777 04/03/2025 Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review, the facility failed to store, prepare, distribute, and serve foods in accordance with professional standards for food service safety. This had the potential to affect 79 residents in the facility. The facility identified two residents (21 and #137) who did not receive food from the kitchen. The facility census was 81. Findings include: Observation of the kitchen's reach in coolers on 03/31/25 at 8:25 A.M. revealed the following: a. a plastic tub of yogurt, opened and partially used, with no open date b. a bag of spinach with an open date of 03/20 c. two packages of lunch meat, opened and not dated d. a bag of hotdogs, opened, not sealed, not dated e. a plastic container of cheese slices, not labeled, not dated f. a bag of garlic cloves, opened, partially used, not dated g. a plastic container of chickpea patties, not labeled, not dated, and the cover was not properly affixed to the container Interview at the time of the observation, [NAME] #357 verified the yogurt was not dated, the spinach was outdated, lunch meat was not dated, hot dogs and cheese slices were not sealed or dated, garlic cloves were not dated, and the chickpea patties were not labeled, dated, or properly sealed. Observation of the dry storage area on 03/31/25 at 8:35 A.M., revealed a bag of penne pasta, which appeared to be torn open, not sealed, and not dated. Interview at the same time, [NAME] #357 verified the bag of penne pasta was not sealed or dated. Observation of the facility's walk-in cooler on 03/31/25 at 8:37 A.M., revealed a bag of lettuce, opened, partially used, and had no open date. The lettuce was brown and had a best by date of 03/16/25. Further observation revealed a bag of parmesan cheese, opened, partially used, not sealed, and no open date. Interview at the same time, [NAME] #357 verified the lettuce was not dated, brown, and had a best by date of 03/16/25 and the parmesan cheese was not sealed or dated. Review of the facility policy titled Food Safety and Sanitation, dated 2019, revealed food should be protected from contamination (dust, flies, rodents), all time and temperature control for safety foods (including leftovers) should be labeled, covered, and dated when stored. When a food package is opened, the food item should be marked to indicate the open date, and this date will be used to determine when to discard the food. Leftovers are used or discarded within 72 hours. Perishable foods with expiration dates are used prior to the use by date on the package. 365777 Page 5 of 7 365777 04/03/2025 Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview, the facility failed to ensure trash cans in the kitchen food preparation areas were covered. This had the potential to affect 79 residents in the facility. The facility identified two residents (#21 and #137) who did not receive food from the kitchen. The facility census was 81. Residents Affected - Many Findings include: Observation on 03/31/25 at 8:30 A.M. revealed a trash can in the food preparation area by the stove was not covered. Interview at the same time, [NAME] #357 verified the trash can did not have a lid. [NAME] #357 stated she looked for a lid and was not able to locate one. Observation on 04/02/25 at 11:47 A.M., the trash can in the food preparation area remain uncovered. Review of the facility policy titled, Food Safety-Director of Food and Nutrition Services' Responsibilities, dated 2019 revealed the director of food and nutrition services assures sanitary conditions are maintained in food storage, preparation, and serving areas and proper waste disposal methods. 365777 Page 6 of 7 365777 04/03/2025 Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review the facility failed to maintain accurate records for supplemental orders. This had the potential to affect one (77) of the seven residents reviewed for resident orders. The census was 81. Findings Include: Review of the medical record for Resident #77, revealed an admission date of 01/16/24. Diagnoses included but were not limited to metabolic encephalopathy, urinary tract infection, and Coronavirus (COVID-19). Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #77 had severe cognition evidenced by a Brief Interview for Mental Status (BIMS) of 00. The resident was dependent on staff for activities of daily living (ADLs). Review of physician orders for Resident #77 dated 01/18/25, revealed the resident was ordered Ensure (supplement) with meals. Review of the weights documented for Resident #77 revealed a weight change of 5.37 percent (%). A documented weight on 02/13/25 revealed her weight to be 201.00 lbs. and on 03/10/25 revealed a documented weight to be 190.2 lbs. No evidence of a reweight or notification to the Registered Dietician (RD) or the physician. An interview on 04/02/25 at 10:07 AM with Certified Nursing Assistant (CNA) #488, revealed an Ensure was only given if the resident didn't eat her meals. CAN #488 stated they wait for her private caregiver to come in to feed her or give her an Ensure. An interview on 04/02/25 at 10:45 A.M. with the Dietician Technician (DT), revealed Resident #77's family feeds her, but the staff should be giving her the magic cup and Ensure supplement. An interview on 04/02/25 at 10:58 A.M. with Licensed Practical Nurse (LPN) #510, revealed she documented the Ensure in the medication administration record (MAR) according to what the family reported to her; however, she never verified if the ensure was consumed or not. An interview on 04/02/2025 at 11:00 A.M. with Director of Nursing (DON) stated that staff should administer the ensure (supplement order) and accurately document. 365777 Page 7 of 7