Health 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. Page 1 of 3 365979 365979 03/04/2024 Trinity Community at Fairborn 789 Stoneybrook Trail Fairborn, OH 45324

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of policy titled, Notification and reporting of changes in health status, illness, injury and death of a resident, dated 07/19/16 revealed the nursing home administrator or designee shall immediately inform the resident, consult with the resident's physician, and notify the resident's sponsor or authorized representative, with the resident's permission, and other proper authority, in accordance with state and local laws and regulations when there is a need to alter treatment significantly such as a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. This deficiency represents non-compliance investigated under Complaint Number OH00151021. 365979 Page 2 of 3 365979 03/04/2024 Trinity Community at Fairborn 789 Stoneybrook Trail Fairborn, OH 45324

F 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure the admission agreement was signed or explained to the resident or resident's representative. This affected one (Resident #84) of three residents reviewed for admission agreements. 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 the admission agreement for Resident #84 revealed the agreement was not signed by the resident or resident's representative. Interview on 03/04/24 at 12:41 P.M. with the Administrator verified Resident #84's admission agreement was not signed. The Administrator stated Admissions Coordinator (AC) #629 could not seem to get with the resident's representative to get the papers signed. Interview on 03/04/24 at 1:33 P.M. with AC #629 verified Resident #84 nor his representative did not sign the admission agreement and the admission packet was not completed. AC #629 could not remember if the resident and his representative were given the information or if the information was explained to them. Review of policy titled, admission Policy, revised 08/17 revealed resident requirements: sign admission agreement and agree to abide by all facility policies and procedures. admission process, the admission agreement, admission authorizations, notice of acknowledgements and other appropriate documents will be signed by the resident and, as applicable, a designated representative and uploaded by the admission coordinator into the electronic health record system. This deficiency represents non-compliance investigated under Complaint Number OH00151021. 365979 Page 3 of 3