Beavercreek, OH

Trinity Community

3-star overall rating with 2-star inspections with $24,453 in total fines with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

3218 Indian Ripple Road, Beavercreek, OH

(937) 426-8481

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

United Church Homes

Operator or chain grouping

Approved since

1990-01-23

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

6 facilities

Chain averages 3 overall / 3 health / 3 staffing / 5 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.48

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.26

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.49

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

4.23

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.74

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

3.82

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.19

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.46

CMS adjusted RN staffing hours

Adjusted total hours

4.06

CMS adjusted total nurse staffing hours

Case-mix index

1.43

Higher values indicate more complex resident acuity

RN turnover

43%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

39%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,399

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

26.89

Composite VBP score used to determine payment impact.

Payment multiplier

0.9843

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0.92

Baseline 19.40% · Performance 21.01% · Measure score 0.92 · Achievement 0.92 · Improvement 0

Healthcare-associated infections

Baseline 7.03% · Performance 7.77% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

7.67

Baseline 79.12% · Performance 34.78% · Measure score 7.67 · Achievement 7.07 · Improvement 7.67

Adjusted total nurse staffing

2.17

Baseline 3.76 hours · Performance 3.69 hours · Measure score 2.17 · Achievement 2.17 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	8.63%	10.72% 2.1 pts better	No Different than the National Rate · Eligible stays 168 · Observed rate 5.95% · Lower 95% interval 5.79%
Discharge to community	63.7%	50.57% 13.1 pts better	Better than the National Rate · Eligible stays 172 · Observed rate 57.56% · Lower 95% interval 56.77%
Medicare spending per beneficiary	0.87	1.02 0.2 pts better
Drug regimen review with follow-up	97.94%	95.27% 2.7 pts better	Numerator 95 · Denominator 97
Falls with major injury	1.03%	0.77% 0.3 pts worse	Numerator 1 · Denominator 97
Discharge self-care score	44.44%	53.69% 9.2 pts worse	Numerator 28 · Denominator 63
Discharge mobility score	52.38%	50.94% 1.4 pts better	Numerator 33 · Denominator 63
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 97 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	7.77%	7.12% 0.6 pts worse	No Different than the National Rate · Eligible stays 106 · Observed rate 8.49% · Lower 95% interval 4.23%
Staff COVID-19 vaccination coverage	7.52%	8.2% 0.7 pts worse	Numerator 10 · Denominator 133
Staff flu vaccination coverage	74.49%	42% 32.5 pts better	Numerator 146 · Denominator 196
Discharge function score	41.27%	56.45% 15.2 pts worse	Numerator 26 · Denominator 63
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 61 · Denominator 61
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	19.57%	25.2% 5.6 pts worse	Numerator 9 · Denominator 46

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.5	1.8 0.3 pts better	1.9 0.4 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.3	1.8 0.5 pts better	1.8 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	92.4% 7.2 pts better	93.4% 6.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	94.5% 5.5 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	5.4%	3.3% 2.1 pts worse	3.3% 2.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 4.7% · Q3 6.5% · Q4 4.5% · 4Q avg 5.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	5.2%	26.1% 20.9 pts better	11.4% 6.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.5% · Q3 3.5% · Q4 6.5% · 4Q avg 5.2%
Percentage of long-stay residents who lose too much weight	6.4%	6.2% 0.2 pts worse	5.4% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 8.0% · Q3 8.0% · Q4 5.9% · 4Q avg 6.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	14.6%	25.4% 10.8 pts better	19.6% 5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 13.7% · Q3 15.7% · Q4 17.6% · 4Q avg 14.6%
Percentage of long-stay residents who received an antipsychotic medication	9.3%	11.5% 2.2 pts better	16.7% 7.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 7.1% · Q3 11.9% · Q4 9.5% · 4Q avg 9.3% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	9.9%	7.7% 2.2 pts worse	16.3% 6.4 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 9.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	8.4%	6.2% 2.2 pts worse	14.9% 6.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 16.7% · Q3 12.8% · Q4 2.2% · 4Q avg 8.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.2% 0.2 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.8%	0.5% 0.3 pts worse	1.7% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.6% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	16.6%	21.7% 5.1 pts better	19.8% 3.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 15.2% · Q3 16.3% · Q4 23.4% · 4Q avg 16.6%
Percentage of long-stay residents with pressure ulcers	3.8%	3.7% 0.1 pts worse	5.1% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 5.0% · Q3 3.6% · Q4 2.1% · 4Q avg 3.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	96.4%	78.1% 18.3 pts better	81.7% 14.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 94.9% · Q2 95.5% · Q3 97.4% · Q4 97.9% · 4Q avg 96.4%
Percentage of short-stay residents who had an outpatient emergency department visit	10.0%	12.5% 2.5 pts better	12.0% 2 pts better	Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 8.9% · Expected 9.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.7%	1.2% 0.5 pts worse	1.6% 0.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 3.2% · Q4 2.3% · 4Q avg 1.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	94.2%	75.6% 18.6 pts better	79.7% 14.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 94.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.1%	25.1% 5 pts better	23.9% 3.8 pts better	Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 17.7% · Expected 21.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-03 · Fire 2025-04-03

6 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2022-04-25 · Fire 2022-04-25

11 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2019-02-28 · Fire 2019-02-28

14 health deficiencies

Top issue: Resident Assessment and Care Planning (5 deficiencies)

4 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-04-03

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-05-01

F · Potential for more than minimal harm 2025-04-03

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-05-01

E · Potential for more than minimal harm 2025-04-03

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2025-05-01

E · Potential for more than minimal harm 2025-04-03

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-05-01

E · Potential for more than minimal harm 2025-04-03

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-05-01

E · Potential for more than minimal harm 2025-04-03

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-05-01

E · Potential for more than minimal harm 2025-04-03

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-05-01

F · Potential for more than minimal harm 2022-04-25

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2022-06-20

F · Potential for more than minimal harm 2022-04-25

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-06-20

F · Potential for more than minimal harm 2022-04-25

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2022-06-20

F · Potential for more than minimal harm 2022-04-25

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2022-06-20

F · Potential for more than minimal harm 2022-04-25

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-06-20

F · Potential for more than minimal harm 2019-02-28

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2019-04-08

E · Potential for more than minimal harm 2019-02-28

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2019-04-08

E · Potential for more than minimal harm 2019-02-28

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2019-04-08

E · Potential for more than minimal harm 2019-02-28

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-04-08

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-04-03

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-05-01

F · Potential for more than minimal harm 2025-04-03

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2025-05-01

D · Potential for more than minimal harm 2025-04-03

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2025-05-01

D · Potential for more than minimal harm 2025-04-03

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2025-05-01

D · Potential for more than minimal harm 2025-04-03

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-05-01

D · Potential for more than minimal harm 2025-04-03

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-05-01

G · Actual harm 2024-04-18

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-04-19

D · Potential for more than minimal harm 2023-08-21

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-09-11

D · Potential for more than minimal harm 2023-08-21

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2023-09-11

J · Immediate jeopardy 2023-04-10

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-04-11

E · Potential for more than minimal harm 2022-04-25

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2022-06-20

D · Potential for more than minimal harm 2022-04-25

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2022-06-20

D · Potential for more than minimal harm 2022-04-25

F578 · Resident Rights Deficiencies

Health

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.

Corrected 2022-06-20

D · Potential for more than minimal harm 2022-04-25

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2022-06-20

D · Potential for more than minimal harm 2022-04-25

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2022-06-20

D · Potential for more than minimal harm 2022-04-25

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2022-06-20

D · Potential for more than minimal harm 2022-04-25

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2022-06-20

D · Potential for more than minimal harm 2022-04-25

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2022-06-20

D · Potential for more than minimal harm 2022-04-25

F810 · Nutrition and Dietary Deficiencies

Health

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Corrected 2022-06-20

D · Potential for more than minimal harm 2022-04-25

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-06-20

E · Potential for more than minimal harm 2019-02-28

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2019-04-08