Inspection·July 31, 2025

F 0698 2564248. 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 2 of 4 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 07/31/2025 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)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, staff interviews, an interview with the pest control provider, review of pest control invoices, and review of facility policy, the facility failed to maintain an effective pest control program. This affected three (Residents #62, #70, and #71) of six residents sampled for pest control and had the potential to affect all 21 residents living on the 400-Hall. The facility census was 84.Findings include: 1.Review of the medical record revealed Resident #62 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, type II diabetes, chronic combined congestive heart failure, end stage renal disease, unspecified dementia, and unspecified anxiety. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. 2. Review of the medical record revealed Resident #70 was admitted to the facility on [DATE]. Diagnoses included hemiparesis and hemiplegia following cerebral infarction, morbid obesity, chronic combined congestive heart failure, major depressive disorder, and stage II chronic kidney disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. 3. Review of the medical record revealed Resident #71 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, unspecified anxiety disorder, unspecified depression, stage II chronic kidney disease, generalized weakness, and repeated falls. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 had severely impaired cognition, did not reject care, had occasional self-directed behaviors, and wandered occasionally. Observation on 03/31/25 at 11:04 A.M. revealed Resident #70 was seated in her wheelchair at bedside watching television (T.V.) There were two small, winged insects flying near her head. There were two bags of apples on the top shelf of a cabinet located against the wall directly in front of the resident with five large black flies swarming around the fruit. During an interview on 07/31/25 at 11:04 A.M. Resident #70 stated she had gnats and flies in her room all the time, but she never saw the facility spray for pests. During an interview on 07/31/25 at 11:06 A.M. Medication Aide #125 verified Resident #71 had multiple winged insects in her room flying near her head and near stored fruit. The aide stated Residents #70 and #71 both kept fruit in their room that attracted pests. During an interview on 07/31/25 at 11:21 A.M. Director of Environmental Services (EVS) #95 stated they deep-cleaned Resident #70's room daily and sent letters to families asking them not to bring excessive amounts of perishable foods. The director stated they had routine pest control services monthly and additionally as needed. During a telephone interview on 07/31/25 at 1:56 P.M. Pest Control Technician #150 stated the pest control company did not spray for gnats or flies as this was not allowed in skilled nursing facilities, and stated these pests indicated either a water or sanitation problem. The pest company offered blue-light devices that were hung on the walls to attract and trap/kill flying insects. The company could order these, but the facility would need an electrician to install them. During an observation on 07/31/25 at 4:10 P.M. Resident #62 was observed to lay in bed supine with eyes open. Two winged insects were observed flying around the resident's head. During the concurrent interview, Resident #62 swatted repeatedly at the flying insects. Additional observation in the room revealed a small, winged insect crawling on the toilet seat. During an interview on 07/31/25 at 4:12 P.M. Resident #62 stated there were frequently flies in his room and they drove him crazy. During an interview on 07/31/25 at 4:15 P.M. Medication Aide #125 verified Resident #62 had flying insects in his room and bathroom. Observation on 07/31/25 at 4:18 P.M. revealed greater than twenty winged insects were seen in Resident #70 and #71's shared room flying Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365979 If continuation sheet Page 3 of 4 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 07/31/2025 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)

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete around bags of apples, and crawling on the ceiling, walls, and privacy curtain. Resident #70 was not in the room. Resident #71 was standing at bedside with walker swatting at winged insects as they neared her face. During an interview on 07/31/25 at 4:18 P.M. Resident #71 indicated there were flying insects in her room all the time. During an interview on 07/31/25 at 4:20 P.M. Certified Nursing Assistant (CNA) #120 verified there were more than 20 flying insects in Resident #70 and #71's shared room. CNA #120 stated she had made numerous complaints to management about the flies on 400-Hall, but nothing was done. CNA #120 stated at times she brought an electric flyswatter to work to kill as many as she could, but the flies and gnats were always back the next time she worked. Review of pest control invoices dated 05/01/25, 05/27/25, 06/03/25, and 07/01/25 revealed the pest control company treated the facility for mice, ants, and cockroaches. Review of policy titled Pest Control, not dated, revealed the facility maintained an on-going pest control program to ensure that the building was kept free of insects. This deficiency represents noncompliance investigated under Complaint Number 1388109. Event ID: Facility ID: 365979 If continuation sheet Page 4 of 4