Inspection·June 11, 2024

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, interview ,record review, facilities investigation review, and policy review, revealed the facility failed to implement abuse policies to report allegations of resident abuse. This affected one resident, (Resident #25) of three residents reviewed for reporting abuse . The total facility census was 86. Residents Affected - Few Findings Include: Record review of alleged victim Resident #25 revealed the resident was admitted to the attached skilled living facility on 11/19/20. The resident had a legal guardian and resided on the skilled living unit. Diagnoses for Resident #25 included age related physical debility, diabetes, atrial fibrillation, morbid obesity, dementia, psychosis, communication deficit, depressive disorder, muscle weakness, intellectual disabilities, and cerebrovascular disease. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and required maximum assistance of one for transfers and mobility. Review of the State Reportable Incident, (SRI) dated 06/06/24 revealed the facility was notified on 06/06/24 of an alleged kissing encounter between Resident #36, the perpetrator, residing on the attached residential care unit, and Resident #25, the alleged victim, residing on the skilled care unit. Record review of Resident #36 revealed the resident was admitted to the Residential Care unit of the facility on 05/25/24 and discharged to the attached skilled living unit on 06/06/24. The resident was his own responsible party. Diagnoses for Resident # 36 include dementia, behavioral disturbance on 06/07/24, communication deficit, aphagia, reduced mobility, tachycardia, chronic kidney disease, depression, and transient cerebral attack. Review of MDS dated [DATE], revealed Resident #36 had severely impaired cognition rating a three scored out of 15 on the Brief Interview Mental Status, (BIMS) exam. The resident was independent for walking and required supervision for personal hygiene. Review of the facility investigation of alleged sexual encounter of Resident #36 towards Resident #25, dated 06/06/24 revealed, the Administrator was notified by State Tested Nurse Aide, (STNA) #73 that STNA #60 witnessed male Resident #36 kissing female Resident #25 on 06/03/24. STNA #60 had not notified the Administrator of the incident of 06/03/24. Review of STNA #60 witness statement, dated 06/07/24, revealed on 06/03/24 at 2:30 A.M., Resident #25's roommate activated the call light. STNA #60 witnessed Resident #36 sitting on Resident #25's bed, leaning over kissing her. Review of STNA #70 statement revealed she responded after hearing STNA #60 state get off her get out of her bed. STNA (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 365979 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 06/11/2024 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)