Inspection·March 4, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure a resident's representative was notified of medication changes. This affected one (Resident #84) of three residents reviewed for notifications. The facility census was 83. Findings include: Review of the medical record for Resident #84 revealed an admission date of 07/22/23 and discharge date of 08/24/23. Diagnoses including but not limited to lobar pneumonia, acute respiratory failure with hypoxia, dementia with behavioral disturbance, depression, and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 had severe cognitive impairment. Resident #84 required extensive assistance for activities of daily living, supervision for ambulation, and was independent for eating. Review of physician orders revealed an order for Seroquel 25 milligrams (mg) at bedtime was decreased to seroquel 12.5 mg on 08/18/23 and Zoloft 25 mg was discontinued on 08/18/23. Review of the progress note dated 08/07/23 at 3:21 P.M. revealed a pharmacy gradual dose reduction was declined due to the resident not being appropriate at the time to decrease Seroquel. Resident #84 required one-time doses of Haldol during his stay for increased aggression and combativeness at nighttime. Review of the practitioner/physician note dated 08/17/23 revealed Resident #84 was very confused and required a lot of cues with activities of daily living. The resident required a lot of distractions to prevent the resident from falling. Resident #84 was restless and constantly wanting to be moving. On today's visit, would like to taper down Seroquel to 12.5 mg at bedtime and discontinue Zoloft since the resident is on Remeron. Left a message for the resident's wife to call to discuss code status. Further review of the progress notes revealed no documentation Resident #84's representative was notified of the decreased Seroquel or discontinuation of Zoloft. Interview on 03/04/24 at 2:05 P.M. with Director of Nursing (DON) #685 verified there was no documentation to indicate the resident's representative was notified of Zoloft being discontinued or Seroquel being decreased. (continued on next page) 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 3 Event ID: 365979 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 365979 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Community at Fairborn 789 Stoneybrook Trail Fairborn, OH 45324 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)