Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Trinity Community during CMS and state inspections, most recent first.
Surveyors found that food items in the kitchen, coolers, and storage areas were not properly labeled, sealed, or dated, with some items being outdated or improperly stored. Staff confirmed these issues, and the facility's policy requiring proper labeling and dating of food was not followed. This had the potential to affect 79 residents, with two residents not receiving food from the kitchen.
Surveyors found that a trash can in the kitchen food preparation area was left uncovered, and a staff member confirmed the absence of a lid. The issue persisted during a follow-up observation, despite facility policy requiring proper waste disposal and sanitary conditions. This had the potential to affect 79 residents who received food from the kitchen.
A resident with multiple mental health diagnoses, including bipolar disorder and psychotic disorder with delusions, was not referred for a PASARR level II evaluation after a significant change in mental health status. The facility did not submit the required application to the state agency, and staff confirmed the lack of documentation or referral, despite policy requiring such action.
Three residents with complex medical conditions did not have baseline care plans developed within 48 hours of admission, as required by facility policy. Staff interviews and medical record reviews confirmed that care plans were either delayed or not completed in a timely manner, impacting the prompt identification and planning for residents' immediate needs.
Staff did not consistently document dinner meal intakes for a resident with severe cognitive impairment and total dependence on staff, resulting in incomplete monitoring of nutritional intake over an extended period. This deficiency was confirmed by a Dietician Tech and identified through record review and staff interview.
A resident with severe cognitive impairment and significant weight loss did not consistently receive a physician-ordered nutritional supplement as required. Staff relied on family to provide the supplement and documented administration based on family reports rather than direct observation, resulting in inaccurate medical records and failure to follow professional standards.
The facility failed to follow protocol for managing low blood pressure in a resident, leading to hospitalization for hypotension, acute kidney injury, and altered mental status. Despite low blood pressure readings, staff did not hold medications or notify the physician, resulting in significant harm.
Improper Food Storage and Labeling in Kitchen and Storage Areas
Penalty
Summary
Surveyors observed multiple instances of improper food storage and handling in the facility's kitchen, reach-in coolers, dry storage, and walk-in cooler. Specific findings included opened and partially used food items such as yogurt, lunch meat, hot dogs, cheese slices, garlic cloves, chickpea patties, spinach, lettuce, and parmesan cheese that were not labeled with open dates, not sealed, or not properly covered. Some items, such as spinach and lettuce, were found to be outdated or past their best by dates, and the lettuce was noted to be brown. Additionally, a bag of penne pasta in the dry storage area was found torn open, unsealed, and undated. Staff interviews at the time of observation confirmed these deficiencies, with staff verifying that the food items were not dated, sealed, or properly labeled as required. The facility's own policy, which mandates that all time and temperature control for safety foods be labeled, covered, and dated, was not followed. The deficiency had the potential to affect 79 residents, and two residents were specifically identified as not having received food from the kitchen.
Uncovered Trash Can in Kitchen Food Preparation Area
Penalty
Summary
Surveyors observed that a trash can in the kitchen food preparation area, specifically by the stove, was not covered during an inspection. At the time of observation, a staff member confirmed that the trash can did not have a lid and reported being unable to locate one. A follow-up observation two days later revealed that the trash can remained uncovered. The facility's policy requires the director of food and nutrition services to ensure sanitary conditions in food storage, preparation, and serving areas, including proper waste disposal methods. The facility census was 81, with two residents identified as not receiving food from the kitchen, potentially affecting 79 residents.
Failure to Refer for PASARR Level II After Significant Mental Health Change
Penalty
Summary
The facility failed to refer a resident for a Pre-Admission Screening and Resident Review (PASARR) level II evaluation after the resident experienced a significant change in mental health status. Medical record review showed that the resident, who had diagnoses including bipolar disorder, psychotic disorder with delusions, and mood disorder, was admitted with these conditions, but these diagnoses were not included in the current PASARR application. There was no documented evidence that an initial or significant change PASARR application was submitted to the state agency after the new mental health diagnoses were identified. Staff interviews confirmed that no such referral or documentation was made, despite facility policy requiring referral for level II review upon significant change in status assessment.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that baseline care plans were developed within 48 hours of admission for three residents out of twelve reviewed. For one resident with multiple diagnoses including congestive heart failure, diabetes, and morbid obesity, the baseline care plan was not initiated until several days after admission. Another resident with vertigo, diabetes, and heart failure did not have a baseline care plan started until well after admission. A third resident with complex medical issues such as toxic encephalopathy, sepsis, kidney failure, and dementia had a baseline care plan started on the day of admission but it was not completed until three days later. Interviews with staff, including an LPN and the DON, confirmed that the baseline care plans were not completed within the required 48-hour timeframe as outlined in the facility's policy. The policy specifies that a baseline care plan or a comprehensive care plan must be developed within 48 hours of admission to ensure the minimum healthcare information necessary to properly care for a resident is available. The failure to meet this requirement was verified through medical record review and staff interviews.
Failure to Monitor and Record Meal Intake for Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to ensure that meal intakes were properly monitored and recorded for a resident with severe cognitive impairment and total dependence on staff for activities of daily living. Medical record review showed that, except for one date, dinner meal intakes were not documented for this resident over a period of nearly two weeks. The resident had multiple diagnoses, including metabolic encephalopathy, urinary tract infection, and COVID-19. This deficiency was confirmed during an interview with the Dietician Tech, who acknowledged that the dinner intakes had not been accurately recorded during the specified timeframe. The lack of documentation was identified through record review, staff interview, and policy review, and affected one of seven residents reviewed for nutrition in a facility with a census of 81.
Failure to Accurately Administer and Document Physician-Ordered Nutritional Supplement
Penalty
Summary
The facility failed to maintain accurate records and ensure proper administration of a physician-ordered nutritional supplement for a resident with severe cognitive impairment and multiple diagnoses, including metabolic encephalopathy, urinary tract infection, and COVID-19. The resident was dependent on staff for activities of daily living and had a documented weight loss of 5.37% over a one-month period. There was no evidence in the medical record of a reweight or notification to the registered dietician or physician regarding the weight change. Staff interviews revealed inconsistent practices regarding the administration and documentation of the Ensure supplement. A CNA reported that Ensure was only given if the resident did not eat her meals and that they waited for the private caregiver to feed her or provide the supplement. The dietician technician stated that staff should be administering the supplement, regardless of family involvement. An LPN admitted to documenting the supplement administration in the MAR based on family reports without verifying actual consumption. The DON confirmed that staff are responsible for administering and accurately documenting the supplement order.
Failure to Follow Protocol for Low Blood Pressure
Penalty
Summary
The facility failed to ensure that Resident #77 received appropriate treatment and care according to professional standards. Specifically, the facility did not hold blood pressure medications or notify the physician when Resident #77 exhibited low blood pressure readings. On 03/04/24, Resident #77's blood pressure was recorded at 98/43 mmHg at 7:43 A.M., and the blood pressure medications were administered without notifying the doctor. Later that morning, at 9:32 A.M., the resident's blood pressure dropped further to 88/32 mmHg, and although the propranolol was held, the physician was still not notified. This lack of action led to Resident #77 being hospitalized with diagnoses of hypotension, acute kidney injury, and altered mental status, with significantly elevated BUN and creatinine levels. The resident was hospitalized for nine days before returning to the facility. Resident #77 had a complex medical history, including hypertension, atrial fibrillation, chronic peripheral venous insufficiency, and dementia, among other conditions. The resident was moderately cognitively impaired and required various levels of assistance for daily activities. Despite these complexities, the facility's staff did not follow the established protocol for managing hypotension, which included holding blood pressure medications for systolic blood pressure below 100 mmHg and notifying the physician for systolic blood pressure below 90 mmHg. Interviews with the facility's staff and the Medical Director confirmed that the physician was not notified of the low blood pressure readings on 03/04/24. The Medical Director indicated that appropriate actions, such as holding all blood pressure medications, drawing labs, and administering midodrine, would have been taken if notified. The facility's protocol for managing hypotension was not followed, leading to the resident's hospitalization and subsequent harm. The deficiency was investigated under Complaint Number OH00152332.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Beavercreek
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Village At The Greene | 2.4 mi | ★★★★★ | 4 | 0 |
| Beavercreek Post Acute | 3.6 mi | ★★★★★ | 0 | 0 |
| Oak Creek Terrace Inc | 4.1 mi | ★★★★★ | 3 | 0 |
| Bellbrook Health And Rehab | 4.4 mi | ★★★★★ | 21 | 0 |
| Kettering Heights Post Acute | 4.6 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.