Inspection·May 16, 2019

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wife are both wanting to know if you would consider a one time order for his tonight to help his pain. Something we have available in the emergency medication box. LPN #104 had asked pharmacy at noon and they denied access for this script as he is going to get a higher dosage tomorrow, please advise, sent to physician. Interview on 05/14/19 at 2:31 P.M. with Unit Manager Registered Nurse (RN) # 9 confirmed that LPN #104 did not follow up with this message to ensure the physician received the message, when she did not get a response back from the physician, as she should have per their policy. Interview on 05/15/19 at 8:00 A.M., with Licensed Practical Nurse (LPN) #104 revealed she was the nurse working on 04/15/19 and 04/25/19. A review of the narcotic sign out sheet for the Lyrica 150 mg three times a day was reviewed with LPN #104. The narcotic sign out sheet identified LPN #104 signed out the Lyrica 150 mg on 04/15/19 at 8:00 A.M. and 3:00 P.M. LPN# 104 revealed that on 04/15/19, Resident #12 was ordered to receive Lyrica 100 mg twice a day and she removed the 8:00 A.M. and 3:00 P.M. doses from the wrong card. She administered the 150 mg dose instead of the 100 mg dose. This caused Resident #12 to be short of her 150 mg doses on 04/25/19 at 12:00 P.M. and 4:00 P.M. and unable to receive the pain medication. LPN #104 also revealed that she later realized that she had removed the 12:00 P.M. and 4:00 P.M. doses on 04/15/19 from the wrong card. LPN #104 verified Resident #12 received the wrong dose of medication twice on 04/15/19 and did not receive two ordered doses on 04/25/19. LPN #104 revealed she did send a text message to the physician to ask if there was something else he could have for leg pain in order to get him thorough the night. LPN #104 revealed she sent the message after 6:00 P.M. and thought it was too late for an answer back. LPN #104 also revealed that her shift had ended and she left after sending the message to the physician so she was unaware if the physician ever responded or received the message. Review of facility policy titled Missed Medications dated October 2018 revealed the physician is to be notified as soon as possible when a resident misses a medication due to unavailability from the pharmacy. If a resident is out of a medication, it is the responsibility of the nurse on duty to reorder the medication immediately though the pharmacy, inform the physician as son of possible of the missed medications name and dose, document the notification the progress notes. If the pharmacy is unable to fill the medication, the family is to be notified in case they can assist in filling the prescription. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365979 If continuation sheet Page 2 of 16 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 05/16/2019 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)

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents were issued Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) notices upon discharge from Medicare Part A Services with benefit days remaining when they continued to reside in the facility. This affected two (#67 and #68) of three residents reviewed for beneficiary protection notification. The facility census was 79. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #67 was admitted to the facility on [DATE], with a re-entry date of 04/07/19. Diagnoses included encephalopathy, urinary tract infection, pneumonia, congestive heart failure, and cerebral infarction. Review of 30 day Minimum Data Set (MDS) assessment dated [DATE] revealed severely impaired cognitive skills for daily decision making, extensive assistance was required with bed mobility, transfers, eating, toileting, and personal hygiene. Review of Notice of Medicare Non-coverage dated 05/06/19 revealed Medicare Part A Skilled Services would end on 05/08/19. The medical record did not contain a SNF ABN notice. 2. Medical record review revealed Resident #68 was admitted to the facility on [DATE], with diagnoses including right leg fracture and pneumonia. Review of 14 day MDS dated [DATE] revealed moderately impaired cognitive skills for daily decision making. Extensive assistance was required with all activities of daily living (ADLs) except for limited assistance with eating. Review of Notice of Medicare Non-coverage dated 04/30/19 revealed Medicare Part A Skilled Services would end on 05/02/19. The medical record did not contain a SNF ABN notice. Interview on 05/15/19 at 4:15 P.M., with Social Services #32 reported it was unclear at the time Medicare Part A Skilled Services ended for Residents #67 and #68 if they were going to remain in the facility or go home. As a result, SNF ABN notices were not issued and it was decided both residents would remain in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365979 If continuation sheet Page 3 of 16 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 05/16/2019 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)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of facility submitted self reported incidents (SRIs), and review of facility policy, resident and staff interview, the facility failed to implement the facility policy on reporting allegations of verbal abuse. This affected three (#16, #21, and #80) of three residents reviewed for abuse. The census was 79. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #16 was admitted to the facility on [DATE], with diagnosis including Alzheimer's disease. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed severely impaired cognitive skills for daily decision making, supervision was required with bed mobility, transfers, eating, and extensive assistance was required with toileting and personal hygiene. Resident #16 did not require any mobility devices. Review of care plan dated 11/04/15 revealed Resident #16 required a Alzheimer/dementia special care unit related to dementia. On 01/30/17, Resident #16 was moved to a behavior unit due to increased behaviors. Observation on 05/16/19 at 12:49 P.M., revealed Resident #16 was seated in the dining room eating independently. Resident #16 was calm with appropriate behavior but was unable to be interviewed due to a confused mental status. 2. Closed medical record review revealed Resident #80 was admitted to the facility on [DATE] and discharged on 04/24/19. Diagnosis included Alzheimer's disease. Review of quarterly MDS dated [DATE] revealed moderately impaired cognitive skills for daily decision making, extensive assistance was required with dressing, toileting, personal hygiene, supervision was required with bed mobility, transfers, and eating. Resident #80 did not utilize any mobility devices. Review of care plan initiated 08/26/16, revealed Resident #80 required a special care unit related to dementia and was moved to a secure behavior unit due to aggressive behaviors on 08/26/16. A care plan initiated 11/21/16 revealed Resident #80 liked to wander and explore. A care plan initiated 04/24/18 revealed Resident #80 could be impulsive and get a little physical when upset. Review of nursing progress note dated 03/24/19 at 1:19 P.M., revealed the resident was wandering all shift, cursing at staff and other residents, exit seeking, and entering other residents rooms. Redirection and distraction interventions were ineffective. 3. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with a re-entry date of 05/29/15. Diagnosis included paranoid schizophrenia, obsessive compulsive disorder, and bipolar disorder. Review of quarterly MDS dated [DATE] revealed intact cognitive skills for daily decision making and supervision was required with all activities of daily living (ADLs) except for limited assistance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365979 If continuation sheet Page 4 of 16 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 05/16/2019 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)

F 0607 with personal hygiene. A walker was utilized for mobility. Level of Harm - Minimal harm or potential for actual harm Review of care plan dated 07/09/10 revealed Resident #21 displayed some inappropriate interactions with others. Review of care plan dated 01/29/18 revealed Resident #21 had trouble controlling impulses and anger could lead to altercations with others. Residents Affected - Few Review of social service progress note dated 03/25/19 at 9:56 A.M., revealed the social services was being informed by nurse that Resident #21 had displayed escalating behaviors over the weekend. The resident displayed hypervigilance, fixation, and preemptive aggression to perceived threats from other residents. On 03/24/19, Sunday, Resident #21 threw an ice pitcher towards another resident and then subsequently responded aggressively toward the caregiver whom intervened. At breakfast this morning, Resident #21 was asked appropriately by another resident to move out of the way. Resident #21 became hostile, attempted to strike the two residents, required hands on physical containment, and continued to yell threats of harm to others and self. Review of nursing progress note dated 03/25/19 at 10:05 A.M., revealed during breakfast, Resident #21 was standing in the doorway with the breakfast cart behind the resident, blocking the doorway. Two residents attempted to squeeze behind Resident #21, to exit the dining room. One of the residents touches Resident #21 on the back and informed the resident they were just trying to get by. Resident #21 became irate, started screaming and attempted to hit both residents. The nurse immediately intervened and caught Resident #21's hands prior to them making contact with the residents. Resident #21 was screaming at the residents about how he hated them and to get away from him/her. Resident #21 continued to swing at the residents while attempting to break free from the nurse. Resident #21, whom still had medications in his/her mouth, spit medications out, picked up liquid medication located on the medication cart and threw it at the nurse. Resident #21 then screamed at the two residents if either of you go in my room, I'm going to beat the (explicative term) out of you. Resident #21 then proceeded to his/her bedroom and slammed the door. Interview on 05/13/19 at 5:03 P.M., with Resident #21 reported numerous altercations with other residents. Observation at the interview, revealed an alarm was on the bedroom door which chirped every time the door was opened. Observation on 05/14/19 at 3:18 P.M., revealed Resident #21 was awake in bed watching television. Resident #21 was in a semi private room but did not have a roommate. The residents bed was at the rear of the room, near the window. Resident #21 had a barricade surrounding his/her living area which included the privacy curtain pulled, a chair, and tray table from the bed to the opposite wall. Interview with Resident #21, at the time of the observation, reported the alarm to the door was to notify the resident of any intruders. Resident #21 reported he/she preferred to be alone and seldom left the bedroom because he/she didn't want to be around or even look at other people. The resident reported possibly getting kicked out of the dining room as he/she might have had to move a resident in a wheelchair who was in the way. Resident #21 reported staff had instructed him/her to ask for assistance and to get along with others. Interview on 05/15/19 at 2:36 P.M., with Licensed Practical Nurse (LPN) #74 reported on 03/25/19, Resident #21 was already irritated with Resident #80. Resident #80 would wander and enter Resident #21's room, which was the purpose of the alarm to Residents #21's bedroom door. Resident #21 was standing next to the medication cart, near the dining room entrance. Residents #16 and #80 attempted to squeeze by Resident #21 to exit the dining room. Resident #16 touched Resident #21 on the back and informed the resident they were trying to squeeze by when Resident #21 attempted to hit them. LPN #74 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365979 If continuation sheet Page 5 of 16 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 05/16/2019 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)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reported the ability to catch Resident #21's hands and prevent them from making contact with the residents. Resident #21 yelled at the residents to get away and that he/she hated them. The entire time Resident #21 was yelling, he/she was attempting to break free and get to them. Resident #21 was taking medications at the time of the incident, then became angry with LPN #74, spit and threw the medications at LPN #74. The resident then walked away, to his/her bedroom, and informed Residents #16 and #80 if they entered his/her room, they would be beat up. LPN #74 reported the Administrator and social services were notified immediately and Resident #21 was transferred to the hospital for further evaluation the following day. Interview on 05/15/19 at 4:17 P.M., with Social Services (SS) #32 reported the nurse had informed him/her that Resident #21 had thrown an ice pitcher in the direction of Resident #16 the previous weekend and then attempted to hit both Residents #16 and #80 on 03/25/19. Resident #21 was monitored until being transferred to the hospital on [DATE] for further evaluation. Review of facility SRIs revealed no submission was made for the above incident. Interview on 05/16/19 at 9:55 A.M., with the Administrator acknowledged Resident #21 verbally threatened both Resident #16 and #80 but reported a facility self reported incident was not submitted as Resident #21 only physically stuck a staff member, not a resident. Review of facility policy titled Abuse, Mistreatment, Neglect, Exploitation, Injuries of Unknown Source, and Misappropriation of Resident Property dated 03/30/12 revealed abuse included verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. All incident and allegations of Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of resident property and all Injuries of Unknown Source must be reported immediately to the Administrator or designee. The Administrator or designee will notify the State Department of Health of all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident property and injuries of unknown source as soon as possible, but in no even later that 24 hours from the time the incident/allegation was made known to the staff member. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365979 If continuation sheet Page 6 of 16 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 05/16/2019 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of facility submitted self reported incidents (SRIs), and review of facility policy, resident and staff interview, the facility failed to report allegations of verbal abuse to the state agency. This affected three (#16, #21, and #80) of three residents reviewed for abuse. The census was 79. Findings include: 1. Medical record review revealed Resident #16 was admitted to the facility on [DATE], with diagnosis including Alzheimer's disease. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed severely impaired cognitive skills for daily decision making, supervision was required with bed mobility, transfers, eating, and extensive assistance was required with toileting and personal hygiene. Resident #16 did not require any mobility devices. Review of care plan dated 11/04/15 revealed Resident #16 required a Alzheimer/dementia special care unit related to dementia. On 01/30/17, Resident #16 was moved to a behavior unit due to increased behaviors. Observation on 05/16/19 at 12:49 P.M., revealed Resident #16 was seated in the dining room eating independently. Resident #16 was calm with appropriate behavior but was unable to be interviewed due to a confused mental status. 2. Closed medical record review revealed Resident #80 was admitted to the facility on [DATE] and discharged on 04/24/19. Diagnosis included Alzheimer's disease. Review of quarterly MDS dated [DATE] revealed moderately impaired cognitive skills for daily decision making, extensive assistance was required with dressing, toileting, personal hygiene, supervision was required with bed mobility, transfers, and eating. Resident #80 did not utilize any mobility devices. Review of care plan initiated 08/26/16, revealed Resident #80 required a special care unit related to dementia and was moved to a secure behavior unit due to aggressive behaviors on 08/26/16. A care plan initiated 11/21/16 revealed Resident #80 liked to wander and explore. A care plan initiated 04/24/18 revealed Resident #80 could be impulsive and get a little physical when upset. Review of nursing progress note dated 03/24/19 at 1:19 P.M., revealed the resident was wandering all shift, cursing at staff and other residents, exit seeking, and entering other residents rooms. Redirection and distraction interventions were ineffective. 3. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with a re-entry date of 05/29/15. Diagnosis included paranoid schizophrenia, obsessive compulsive disorder, and bipolar disorder. Review of quarterly MDS dated [DATE] revealed intact cognitive skills for daily decision making and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365979 If continuation sheet Page 7 of 16 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 05/16/2019 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few supervision was required with all activities of daily living (ADLs) except for limited assistance with personal hygiene. A walker was utilized for mobility. Review of care plan dated 07/09/10 revealed Resident #21 displayed some inappropriate interactions with others. Review of care plan dated 01/29/18 revealed Resident #21 had trouble controlling impulses and anger could lead to altercations with others. Review of social service progress note dated 03/25/19 at 9:56 A.M., revealed the social services was being informed by nurse that Resident #21 had displayed escalating behaviors over the weekend. The resident displayed hypervigilance, fixation, and preemptive aggression to perceived threats from other residents. On 03/24/19, Sunday, Resident #21 threw an ice pitcher towards another resident and then subsequently responded aggressively toward the caregiver whom intervened. At breakfast this morning, Resident #21 was asked appropriately by another resident to move out of the way. Resident #21 became hostile, attempted to strike the two residents, required hands on physical containment, and continued to yell threats of harm to others and self. Review of nursing progress note dated 03/25/19 at 10:05 A.M., revealed during breakfast, Resident #21 was standing in the doorway with the breakfast cart behind the resident, blocking the doorway. Two residents attempted to squeeze behind Resident #21, to exit the dining room. One of the residents touches Resident #21 on the back and informed the resident they were just trying to get by. Resident #21 became irate, started screaming and attempted to hit both residents. The nurse immediately intervened and caught Resident #21's hands prior to them making contact with the residents. Resident #21 was screaming at the residents about how he hated them and to get away from him/her. Resident #21 continued to swing at the residents while attempting to break free from the nurse. Resident #21, whom still had medications in his/her mouth, spit medications out, picked up liquid medication located on the medication cart and threw it at the nurse. Resident #21 then screamed at the two residents if either of you go in my room, I'm going to beat the (explicative term) out of you. Resident #21 then proceeded to his/her bedroom and slammed the door. Interview on 05/13/19 at 5:03 P.M., with Resident #21 reported numerous altercations with other residents. Observation at the interview, revealed an alarm was on the bedroom door which chirped every time the door was opened. Observation on 05/14/19 at 3:18 P.M., revealed Resident #21 was awake in bed watching television. Resident #21 was in a semi private room but did not have a roommate. The residents bed was at the rear of the room, near the window. Resident #21 had a barricade surrounding his/her living area which included the privacy curtain pulled, a chair, and tray table from the bed to the opposite wall. Interview with Resident #21, at the time of the observation, reported the alarm to the door was to notify the resident of any intruders. Resident #21 reported he/she preferred to be alone and seldom left the bedroom because he/she didn't want to be around or even look at other people. The resident reported possibly getting kicked out of the dining room as he/she might have had to move a resident in a wheelchair who was in the way. Resident #21 reported staff had instructed him/her to ask for assistance and to get along with others. Interview on 05/15/19 at 2:36 P.M., with Licensed Practical Nurse (LPN) #74 reported on 03/25/19, Resident #21 was already irritated with Resident #80. Resident #80 would wander and enter Resident #21's room, which was the purpose of the alarm to Residents #21's bedroom door. Resident #21 was standing next to the medication cart, near the dining room entrance. Residents #16 and #80 attempted to squeeze by Resident #21 to exit the dining room. Resident #16 touched Resident #21 on the back and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365979 If continuation sheet Page 8 of 16 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 05/16/2019 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few informed the resident they were trying to squeeze by when Resident #21 attempted to hit them. LPN #74 reported the ability to catch Resident #21's hands and prevent them from making contact with the residents. Resident #21 yelled at the residents to get away and that he/she hated them. The entire time Resident #21 was yelling, he/she was attempting to break free and get to them. Resident #21 was taking medications at the time of the incident, then became angry with LPN #74, spit and threw the medications at LPN #74. The resident then walked away, to his/her bedroom, and informed Residents #16 and #80 if they entered his/her room, they would be beat up. LPN #74 reported the Administrator and social services were notified immediately and Resident #21 was transferred to the hospital for further evaluation the following day. Interview on 05/15/19 at 4:17 P.M., with Social Services (SS) #32 reported the nurse had informed him/her that Resident #21 had thrown an ice pitcher in the direction of Resident #16 the previous weekend and then attempted to hit both Residents #16 and #80 on 03/25/19. Resident #21 was monitored until being transferred to the hospital on [DATE] for further evaluation. Review of facility SRIs revealed no submission was made for the above incident. Interview on 05/16/19 at 9:55 A.M., with the Administrator acknowledged Resident #21 verbally threatened both Resident #16 and #80 but reported a facility self reported incident was not submitted as Resident #21 only physically stuck a staff member, not a resident. Review of facility policy titled Abuse, Mistreatment, Neglect, Exploitation, Injuries of Unknown Source, and Misappropriation of Resident Property dated 03/30/12 revealed abuse included verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. All incident and allegations of Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of resident property and all Injuries of Unknown Source must be reported immediately to the Administrator or designee. The Administrator or designee will notify the State Department of Health of all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident property and injuries of unknown source as soon as possible, but in no even later that 24 hours from the time the incident/allegation was made known to the staff member. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365979 If continuation sheet Page 9 of 16 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 05/16/2019 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)

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure bed hold notices were provided timely upon hospitalization. This affected two (#21 and #34) of four residents reviewed for hospitalization. The facility census was 79. Findings include: 1. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with a re-entry date of 04/11/19. Diagnoses for Resident #21 included dementia and schizophrenia. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed intact cognitive skills for daily decision making and supervision was required with all activities of daily living (ADLs) except for limited assistance with personal hygiene. Review of social service progress note dated 03/26/19 at 1:00 P.M., revealed Resident #21 was transported to the hospital for evaluation related to increased violent outbursts. Review of nursing progress note dated 04/11/19 at 7:59 P.M., revealed Resident #21 was readmitted to the facility. Review of notification of available bed hold days dated 03/27/19 revealed it was mailed to Resident #21's family on 04/28/19. Interview on 05/16/19 at 11:22 A.M., with admission Coordinator (AC) #37 reported Resident #21 was hospitalized [DATE] to 04/11/19. The notification of available bed hold days was created on 03/27/19, completed upon return to the facility to include accurate number of days remaining, and mailed to the family on 04/28/19. 2. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with a re-entry date of 03/02/19. Diagnoses for Resident #34 included dementia with behavioral disturbance and cerebral infarction. Review of significant change MDS assessment dated [DATE] revealed moderately impaired cognitive skills for daily decision making, total dependence was required with transfers, toileting, personal hygiene, extensive assistance was required with bed mobility and eating. Review of nursing progress note dated 02/25/19 at 5:52 A.M., revealed Resident #34 was transferred to the hospital for a change in condition. Review of progress note dated 03/03/19 at 6:53 A.M., revealed Resident #34 was readmitted from the hospital on [DATE] and remained on antibiotics for pneumonia. Review of Notification of Available Bed Hold Days dated 03/24/19 revealed Resident #34 had 24 leave days available through 12/31/19. It was signed by Resident #34's responsible party on 04/30/19. Interview on 05/16/19 at 11:22 A.M., with AC #37 reported Resident #34 was hospitalized on [DATE]. The Notification of Available Bed Hold Days was initiated upon hospitalization, remaining days were filled in upon residents return to the facility, and the resident representative, whom visited regularly in the evenings, signed the form while at the facility on 04/03/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365979 If continuation sheet Page 10 of 16 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 05/16/2019 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)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident representative and staff interviews, the facility failed to ensure a resident received needed assistance with activities of daily living (ADLs). This affected one (#34) of four residents reviewed for ADLs. The facility census was 79. Residents Affected - Few Findings include: Medical record review revealed Resident #34 was admitted to the facility on [DATE] with a re-entry date of 10/01/17. Diagnoses for Resident #34 included dementia with behavioral disturbance, cerebral infarction, and contracture left hand. Review of significant change Minimum Data Set (MDS) assessment dated [DATE] revealed moderately impaired cognitive skills for daily decision making, total dependence was required with transfers, toileting, personal hygiene, extensive assistance was required with bed mobility and eating. Review of care plan dated 11/28/16 revealed Resident #34 required extensive assistance with daily care, mobility, and was developing a contracture to the left hand. Review of intervention initiated 11/21/17 revealed left palm guard splint to be worn at all times other than to wash. Review of physician order dated 03/20/19 revealed left palm guard at all times. Interview on 05/13/19 at 5:34 P.M., with Resident #34's representative reported Resident #34 had a contracted left hand and long finger nails. The facility did not apply the palm guard, which was located on the bedside table, and did not clean the contacted hand. Observation on 05/14/19 at 2:27 P.M., revealed Resident #34 was asleep in recliner chair. No device was in place to the left hand. Observation on 05/14/19 at 3:52 P.M., revealed Resident #34 was awake in recliner chair without any device in place to the left hand. Observation on 05/15/19 at 7:08 A.M., revealed Resident #34 was up in wheelchair in dining room without any device in place to the left hand. Interview on 05/15/19 at 9:26 A.M., with Licensed Practical Nurse (LPN) #93, during wound treatment to Resident #34, confirmed palm guard was not in place to the left hand. Observation of Resident #34's left hand revealed only the middle finger nail was visible as remaining fingers were curved into palm. The middle finger nail was long, untrimmed, approximately 0.5 centimeters (cm) beyond the base of the finger. LPN #74 reported nursing staff were responsible for cutting finger nails. Interview on 05/15/19 at 10:07 A.M., with State Tested Nursing Assistant (STNA) #87 reported typically Resident #34 would leave the palm guard in place once applied, but may remove the Velcro straps. STNA #87 reported the palm guard had to be applied quickly in the morning or Resident #34 could become combative and reported the palm guard was not applied this morning as STNA #87 didn't have anybody to assist with the application and STNA #87 could not apply it alone. Attempts to apply the palm guard now were unsuccessful as Resident #34 was resistant. Observation on 05/16/19 at 9:16 A.M., revealed Resident #34 was asleep in wheelchair in common area with palm guard in place to left hand. Interview with LPN #2 at the time of the observation, reported Resident #34 typically left the palm guard in place once applied and reported LPN #93 cut (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365979 If continuation sheet Page 11 of 16 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 05/16/2019 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)

F 0677 Resident #34's nails and applied the palm guard. Level of Harm - Minimal harm or potential for actual harm Interview on 05/16/19 at 9:43 A.M., with LPN #93 reported Resident #34's nails were cut and palm guard applied without difficulty. STNA #87 was present and instructed on how to apply the palm guard. All of Resident #34's finger nails were cut and all nails on the left hand were long and extended approximately 0.5 cm beyond the tip of the finger. No skin abnormalities were noted to the palm of Resident #34's left hand. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365979 If continuation sheet Page 12 of 16 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 05/16/2019 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure a resident received care and treatment to non-pressure skin condition. This affected one (#34) of two residents reviewed for non-pressure skin conditions. The facility census was 79. Residents Affected - Few Findings include: Medical record review revealed Resident #34 was admitted to the facility on [DATE] with a re-entry date of 10/01/17. Diagnoses included dementia with behavioral disturbance, cerebral infarction, diabetes, skin cancer, and open scalp wound. Review of significant change Minimum Data Set (MDS) assessment dated [DATE] revealed moderately impaired cognitive skills for daily decision making, total dependence was required with transfers, toileting, personal hygiene, extensive assistance was required with bed mobility and eating. Review of care plan initiated 11/22/16 revealed Resident #34 was admitted with an open wound to the scalp from past surgery and frequently scratches and digs at the open wound and extremities. Interventions included geri sleeve to left leg at all times to prevent picking and keep area covered due to resident's picking behavior. Review of skin assessment dated [DATE] revealed Resident #34 had an open area to the top of the scalp, measuring 4.8 centimeters (cm) by 4.0 cm by 0.1 cm. Resident #34 also had an open areas to the left inner ankle, measuring 1.4 cm by 1.0 cm by 0.1 cm and a scab to the left inner ankle, measuring 2.4 cm by 0.7 cm by 0.1 cm. Review of physician order dated 04/11/19 revealed clean left lower extremity with normal saline. Apply melgisorb calcium alginate and cover with mepilex dressing every day and as needed. On 05/02/19, a physician order revealed clean scalp wound with normal saline, apply double layer of melgisorb calcium alginate to the wound bed, cover the entire wound with mepilex border, and wrap head with kerlex daily and as needed. Observation on 05/14/19 at 3:52 P.M., revealed Resident #34 was awake in recliner chair in bedroom with wound dressing in place to head and geri sleeve in place to left lower extremity. Observation on 05/15/19 at 7:08 A.M., revealed Resident #34 was up in wheelchair in the dining room with bandage to head dated 05/15/19. Resident #34 was attempting to scratch head through bandage and also picking at scabbed areas on top of the left hand. Observation on 05/15/19 at 9:01 A.M., revealed Resident #34 remained up in wheelchair in dinging room. No bandage or geri sleeve was in place to the left lower leg. Resident #34 was scratching at scab area to left lower leg and the area was actively bleeding with blood observed to left lower extremity, hand, and on the resident's clothing. Observation on 05/15/19 at 9:26 A.M., of wound treatment by Licensed Practical Nurses (LPNs) #74 and #93 revealed an approximate one inch diameter open pink area to the scalp on top of Resident #34's head. Upon request, treatment was also completed to the left lower leg which revealed, once the blood was cleaned away, an open dime sized area without any scab remaining. LPN #74 confirmed there wasn't a wound dressing in place and a wound dressing was not located anywhere in the dining room where Resident #34 had remained throughout the morning. LPN #74 reported Resident #34 must have removed the wound dressing during the night, it should have been identified during morning care and replaced, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365979 If continuation sheet Page 13 of 16 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 05/16/2019 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete but LPN #74 reported he/she was not informed the wound dressing was not in place. No geri sleeve was placed on Resident #34's left lower leg. Observation on 05/15/19 at 9:57 A.M., revealed Resident #34 was seated in a wheelchair in the dining room with wound dressing to scalp pushed up on head and almost completely removed. At 10:02 A.M., the scalp dressing was completely removed and only the mepilex border remained in place. Resident #34 was attempting to pick at scalp area. At 10:07 A.M., State Tested Nursing Assistant (STNA) #87 transported Resident #34 back to his/her bedroom and informed LPN #74 about resident removing dressing to scalp. At 10:10 A.M., STNA #87 and LPN #93 attempted to apply palm guard to Resident #34's left hand unsuccessfully. Resident #34 was placed in recliner chair. Wound dressing to the scalp was not reapplied. On 05/15/19 at 11:41 A.M., Resident #34 remained in bedroom, seated in recliner. Resident continued to rub and scratch at scalp wound with only the border dressing in place. Observation of left lower leg revealed the wound dressing had been removed and geri sleeve was not in place. Observation on 05/15/19 at 11:45 A.M., revealed STNA #87 instructed Resident #34 to stop picking at head. Interview with STNA #87, at the time of the observation, confirmed the wound dressing had not yet been replaced since Resident #34 removed it earlier, but the nurse planned to replace it prior to the resident attending bingo activity. Observation on 05/15/19 at 12:18 P.M., revealed Resident #34 had removed the border dressing to the top of the head and now there wasn't anything in place to the scalp wound. Resident #34 was observed digging at wound with finger nails. No wound dressing or geri sleeve was in place to the left lower leg. Observation on 05/15/19 at 12:22 P.M., revealed LPN #93 entered Resident #34's room, repositioned resident for lunch, including elevating feet in recliner chair with left lower leg wound visible, and exited room without acknowledging misplaced wound dressings. Observation on 05/15/19 at 1:34 P.M., revealed wound dressings were in place to both head and left lower leg. Event ID: Facility ID: 365979 If continuation sheet Page 14 of 16 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 05/16/2019 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on record review and staff interview, the facility failed to ensure medications were administered in accordance to the physician's orders. This involved one (#12) of three sampled residents reviewed for medication availability. Facility census was 79. Findings included: Review of Resident #12's medical record revealed and admission date of 02/09/14, with diagnoses included: degenerative joint disease, hypertension, cerebral vascular accident, seizure disorder, dysphasia, chronic obstructive pulmonary disease, depression, paraplegia, anemia, neurogenic bladder, venous thrombosis and embolism. Review of the physician order, dated 04/02/19, revealed Resident #12 was to receive Lyrica 100 milligrams (mg) once a day for seven days. On the second week the Lyrica 100 mg was increased to twice a day, 8:00 A.M. and 4:00 P.M. for seven day. On 04/18/19 the Lyrica was to be increased to 150 mg and given three times a day, 8:00 A.M., 12:00 P.M. and 4:00 P.M., for the next seven days. On 04/26/19, the physician ordered the Lyrica to be increased to 200 mg three times a day: 8:00 A.M., 12:00 P.M. and 4:00 P.M. Review of the Medication Administration Record (MAR) indicated the Lyrica 100 mg was documented as being administered on 04/05-11/19 as ordered. Review of the MAR revealed the Lyrica 100 mg was increased to twice a day, 8:00 A.M. and 4:00 P.M. for seven days, was documented as being administered during those seven days as ordered on 04/12-18/19. Review of the MAR revealed on 04/18/19 the Lyrica was to be increased to 150 mg and given three times a day, 8:00 A.M., 12:00 P.M. and 4:00 P.M. for the next seven days. The MAR revealed that the Lyrica 150 mg was started on 04/18/19 at 4:00 P.M. The MAR documented the medication being administered at 8:00 A.M., 12:00 P.M. 4:00 P.M. on 04/19-24/19, as ordered. On 04/25/19 at 8:00 A.M. the Lyrica 150 mg was administered. Review of the MAR indicated the 12:00 P.M. and 4:00 P.M. doses were not administered. Review of the nurse's progress note dated 04/25/19 at 11:55 A.M., documented this nurse gave the last Lyrica in the cart, then called the pharmacy and filled the paperwork out to get the medication out of the emergency box. When the pharmacy was called back at 12:30 P.M., they refused to allow nurse to pull the Lyrica out of the emergency box. Supervisor and Medical Director notified. Interview on 05/15/19 at 8:00 A.M., with Licensed Practical Nurse (LPN) #104 revealed she was the nurse working on 04/15/19 and 04/25/19. A review of the narcotic sign out sheet for the Lyrica 150 mg three times a day was reviewed with LPN #104. The narcotic sign out sheet identified LPN #104 signed out the Lyrica 150 mg on 04/15/19 at 8:00 A.M. and 3:00 P.M. LPN# 104 revealed that on 04/15/19, Resident #12 was ordered to receive Lyrica 100 mg twice a day and she removed the 8:00 A.M. and 3:00 P.M. doses from the wrong card. She administered the 150 mg dose instead of the 100 mg dose. This caused Resident #12 to be short of her 150 mg doses on 04/25/19 at 12:00 P.M. and 4:00 P.M. and unable to receive the pain medication. LPN #104 also revealed that she later realized that she had removed the 12:00 P.M. and 4:00 P.M. doses on 04/15/19 from the wrong card. LPN #104 verified Resident #12 received the wrong dose of medication twice on 04/15/19 and did not receive two ordered doses on 04/25/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365979 If continuation sheet Page 15 of 16 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 05/16/2019 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)

F 0755 This deficiency substantiates Complaint Number OH00104015. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365979 If continuation sheet Page 16 of 16