01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-04-03 | 6 | 2025-04-03 | 7 |
| Cycle 2 | 2022-04-25 | 10 | 2022-04-25 | 5 |
| Cycle 3 | 2019-02-28 | 14 | 2019-02-28 | 4 |
CMS CCN 3657772026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Trinity Community
3218 Indian Ripple Road · Beavercreek, OH 45440 · Greene County
Certified beds95CMS provider file
Recent citation rows46current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
46 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-04-03 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2025-05-012025-04-03 · HEALTHF0655Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2025-05-012025-04-03 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2025-05-012025-04-03 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-05-012025-04-03 · HEALTHF0814Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
Correction field: Deficient, Provider has date of correction · 2025-05-012025-04-03 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-05-012025-04-03 · FIREK0223Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Correction field: Deficient, Provider has date of correction · 2025-05-012025-04-03 · FIREK0291Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2025-05-012025-04-03 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2025-05-012025-04-03 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-05-012025-04-03 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-05-012025-04-03 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2025-05-012025-04-03 · FIREK0920Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2025-05-012024-04-18 · HEALTHF0684Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-04-19 · complaint2023-08-21 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2023-09-11 · complaint2023-08-21 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Correction field: Deficient, Provider has date of correction · 2023-09-11 · complaint2022-04-25 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2022-06-202022-04-25 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Correction field: Deficient, Provider has date of correction · 2022-06-202022-04-25 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2022-06-202022-04-25 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2022-06-202022-04-25 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2022-06-202022-04-25 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2022-06-202022-04-25 · HEALTHF0756Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Correction field: Deficient, Provider has date of correction · 2022-06-202022-04-25 · HEALTHF0810Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Correction field: Deficient, Provider has date of correction · 2022-06-2003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-04-18 | Fine | $9,932 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- UNITED CHURCH HOMES, INC.Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 04/01/2000
- BAILEY, PETERIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/01/2024
- BATES, TREVORIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 02/01/2017
- BENJAMIN, PAMELAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/01/2021
- BLACK, GEOFFREYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/01/2016
- D'AGOSTINO, JOANNAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/01/2024
- GRAHAM, GEORGEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/01/2025
- GUESS, JAMESIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/01/2021
- HAWES-SAUNDERS, RO NITAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 02/01/2024
- HENRY, JAMESIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 12/31/2014
- JAMES, JILLIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/01/2025
- LONG-HIGGINS, DAVIDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2018
- SANDMAN, ROBERTIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/01/2025
- ULRICH, KARLIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/01/2016
- WILLIAMS, STEPHANIEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/01/2014
- WINFREY, LAPEARLIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/01/2020
- NADERHOFF, JUDITHIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2026
- YOUNG, KENNETHIndividual · CORPORATE OFFICERNOT APPLICABLE · since 02/07/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.92per resident day
RN hours0.49per resident day
Weekend nurse hours3.58per resident day
Staff turnover44.2%CMS reported field
06 / LOCAL RECORDS
Open the Beavercreek ledger →