Health inspection·June 3, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on medical record review, resident interview, staff interview, review of facility Self-Reported Incidents (SRIs) and review of the facility policy, the facility failed to ensure residents were free were free from abuse. This affected one (Resident (#17) of three residents reviewed for abuse. The facility census was 84 residents. Findings include: Review of the medical record for Resident #17 revealed an admission date of 12/24/24 with diagnoses including chronic respiratory failure and failure to thrive. Review of the Minimum Data Set (MDS) assessment for Resident #17 dated 12/30/24 revealed the resident had intact cognition and was dependent on staff for bathing. Review of the care plan for Resident #17 dated 03/06/25 revealed the resident had an ADL (activities of daily living) deficit related to altered respiratory status, deconditioning, and decreased endurance and frequently refused showers. Interventions included permission to receive a shower at any time of choice. Review of the SRI for Resident #17 dated 03/03/25 revealed Resident #44 reported to the Director of Nursing (DON) that on nightshift on 02/28/25 Certified Nursing Assistant (CNA) #370 forced Resident #17 to take a shower. Resident #44 confirmed Resident #17 screamed in protest, but CNA #370 ignored the resident, transferred the resident into a shower chair using a Hoyer lift, and wheeled the resident to the shower room with the resident screaming as the aide pushed the resident down the hallway. Interview with Resident #17 confirmed on 02/28/25 on night shift she told CNA #370 she did not want a shower, that it was illegal for the aide to touch her against her will, but the aide forced her to take a shower. Interview with CNA #300 who was also assigned to the unit confirmed on 02/28/25 he heard yelling found Resident #17 up in the shower chair and very angry. Interview with Registered Nurse (RN) #305 confirmed she heard screaming and went to Resident #17's room and found CNA #370 attempting to get Resident #17 out of bed and into the shower chair while the resident loudly refused. RN #305 confirmed she told CNA #370 to lay the resident back down, but the aide said the resident was already up and the aide wanted to get the shower done. The facility substantiated the allegation of abuse and terminated CNA #370. Interview on 06/02/25 at 10:08 A.M. with Resident #44 confirmed her previous roommate Resident #17 (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 6 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 06/03/2025 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)