Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Trinity Community At Fairborn during CMS and state inspections, most recent first.
A deficiency was identified due to the absence of a pest control program to prevent or manage mice, insects, or other pests within the facility.
A resident with end stage renal disease receiving hemodialysis did not have consistent communication between the facility and the dialysis center, and required pre- and post-dialysis assessments were not completed as ordered. Staff confirmed that communication forms were not returned by the dialysis center, follow-up was not documented, and assessments were missing from the medical record, contrary to facility policy.
A resident with chronic respiratory failure, dependent on staff for bathing, was forced by a CNA to take a shower despite loudly refusing and protesting. The incident was witnessed by another resident and by staff, including a CNA and an RN, who did not intervene or report the event to management. The abuse was only reported days later by another resident, and the facility substantiated the allegation after investigation.
A resident with chronic respiratory failure, dependent on staff for bathing, was forced to take a shower against her will by a CNA, despite her protests. The incident was witnessed by another CNA and an RN, who did not intervene or report the event to management as required. The abuse was only reported days later by another resident, revealing a failure by staff to follow immediate reporting procedures for abuse allegations.
The facility failed to implement effective infection control procedures during a GI outbreak, affecting 13 residents and involving multiple staff call-offs. The DON and ICP did not track residents and employees with symptoms, and the local Health Department was not notified in a timely manner. The facility's infection surveillance policy and CDC guidelines were not followed, contributing to the deficiency.
The facility failed to notify the physician or NPP of significant changes in a resident's health status, specifically elevated blood pressure readings, as required by protocol. A resident with multiple health issues, including hypertension, had several instances of elevated blood pressure documented without physician notification. The facility's policy required such notifications within one business day, but this was not adhered to, as confirmed by a Regional Clinical Nurse.
A facility failed to issue an Advanced Beneficiary Notice (ABN) to a resident after a Notice of Medicare Non-Coverage (NOMNC) was issued, and the resident did not discharge. The resident, with respiratory and anemia diagnoses, was not informed of the last covered date or the cost to remain in the facility. The Business Office Manager confirmed the oversight and noted the absence of a policy on issuing ABNs.
The facility failed to maintain a clean and safe environment for its residents, affecting three individuals. A resident with impaired cognition had a soiled bed and a worn mattress, while another resident's bathroom was found to be dusty and slippery, leading to a fall. Additionally, a resident had a sticky fly strip over her bed due to a fly infestation. These conditions were confirmed by staff, indicating non-compliance with the facility's housekeeping policy.
The facility failed to complete a PASRR for two residents admitted to hospice care, despite significant changes in their conditions. One resident had multiple diagnoses including schizophrenia and dementia, while another had dementia and metabolic encephalopathy. Both were cognitively impaired, and the oversight was confirmed by facility staff.
The facility failed to conduct quarterly care conferences for two residents, one with multiple diagnoses including tachycardia and major depressive disorder, and another with dementia and schizoaffective disorder. Both residents were dependent on staff for ADLs, and the absence of care conferences was confirmed by a social worker.
A facility failed to change a resident's suprapubic urinary catheter as ordered by the physician. The resident, who was severely cognitively impaired and had multiple health issues, was supposed to have the catheter changed every four weeks. However, the scheduled change was missed, and the nurse did not provide a reason for this oversight. The facility lacked a specific policy on following physician's orders for catheter care, relying on standard nursing practices instead.
A resident with a complex medical history did not receive Midodrine as ordered for hypotension. The medication was administered despite the resident's systolic blood pressure exceeding the prescribed threshold on multiple occasions. Facility staff confirmed these discrepancies, indicating a failure to adhere to medication administration guidelines.
A resident, who was cognitively impaired and dependent on staff for medication administration, was found with a bottle of Pepto Bismol at his bedside, contrary to facility protocols. An LPN and a CNA confirmed that the resident was not allowed to have medications at his bedside, as all medications were to be administered by staff. The resident had kept the medication due to feeling nauseated the previous day.
The facility failed to maintain an effective pest control program, affecting a resident and potentially all residents on the 200 unit. A resident's bed was found with gnats and food crumbs, while the dining room had ants due to food debris. The Environmental Service Director acknowledged the issue but did not complete the interview.
A deficiency was identified in a LTC facility where a resident with severe cognitive impairment was allegedly kissed by another resident. The incident, witnessed by an STNA, was not reported to the Administrator or DON as required by the facility's abuse policy. Despite the availability of contact information for reporting, the STNA only mentioned the incident to other staff, leading to a failure in proper communication and reporting processes.
A facility failed to report an alleged abuse incident involving a resident with severe cognitive impairment who was kissed by another resident. Despite witnessing the incident, an STNA did not report it to the Administrator or DON as required. Interviews revealed discrepancies in staff communication, and the facility's policy on immediate reporting was not followed, resulting in a deficiency.
Lack of Pest Control Program
Penalty
Summary
The facility did not have a pest control program in place to prevent or address the presence of mice, insects, or other pests. This deficiency was identified based on observations or findings that indicated the absence of such a program, which is necessary to maintain a sanitary environment for residents. No additional details about specific residents, their medical history, or their condition at the time of the deficiency were provided in the report.
Failure to Ensure Communication and Post-Dialysis Assessment for Dialysis Resident
Penalty
Summary
The facility failed to maintain adequate communication with the dialysis center and did not ensure completion of required post-dialysis assessments for a resident receiving hemodialysis. The resident, who had multiple diagnoses including end stage renal disease, was scheduled for hemodialysis three times weekly at a community-based dialysis center. The care plan and physician orders required pre- and post-dialysis evaluations, and the facility's policy specified that a Hemodialysis Communication Form should be sent with the resident and returned with documentation from the dialysis center. However, the only documented communication from the dialysis center was a single laboratory report, and staff confirmed that the dialysis center did not return completed forms and that follow-up for treatment reports was not documented. Additionally, there was no evidence in the medical record of pre- or post-dialysis assessments being completed for at least one treatment date, and staff interviews confirmed the absence of these assessments and any related nursing notes. The resident reported that papers were not always sent with him to dialysis and that the dialysis center never sent papers back. The facility's policy required staff to review notes from the dialysis service and to call the center if notes were absent, but this process was not followed, resulting in a lack of documented communication and assessment for the resident's dialysis care.
Resident Forced to Shower Against Will; Staff Failed to Report Abuse
Penalty
Summary
A deficiency occurred when a resident with chronic respiratory failure and failure to thrive, who was dependent on staff for bathing and had a care plan allowing showers at their discretion, was forced to take a shower against their will by a CNA. The resident verbally refused the shower, protested loudly, and informed the CNA that it was illegal to be touched against their will, but the CNA proceeded to transfer the resident into a shower chair using a Hoyer lift and wheeled them to the shower room while the resident continued to scream in protest. Another resident witnessed the incident and reported it to the Director of Nursing several days later. During the incident, a CNA and an RN assigned to the unit heard the resident yelling and entered the room, finding the resident in the Hoyer lift protesting the shower. Both staff members assisted in lowering the resident into the shower chair for safety but did not intervene further or report the incident to management. The resident later confirmed that neither the CNA nor the RN listened to their objections or stopped the forced shower. The facility's investigation substantiated the allegation of abuse, confirming that the CNA forced the resident to shower against their will and that other staff present failed to report the incident as required by facility policy. The incident was only brought to management's attention after being reported by another resident several days later.
Failure to Immediately Report Resident Abuse Allegation
Penalty
Summary
A deficiency occurred when staff failed to immediately report an allegation of abuse involving a resident with chronic respiratory failure and failure to thrive, who was dependent on staff for bathing and had a care plan allowing showers at her discretion. On the night in question, a certified nursing assistant (CNA) forced the resident to take a shower against her will, despite the resident's verbal protests and screams. The incident was witnessed by another CNA and a registered nurse (RN), both of whom assisted in lowering the resident into a shower chair but did not intervene further or report the incident to management at the time. The abuse was only reported several days later by another resident to the Director of Nursing (DON), prompting an investigation. Interviews confirmed that the resident had been forced to shower despite her refusal, and that staff present during the incident did not take appropriate action to stop the abuse or notify facility leadership as required by policy. The facility's policy mandates immediate reporting of all abuse allegations to the Administrator for appropriate notifications to state authorities, which did not occur in this case. The failure to report the incident promptly delayed the facility's response and investigation into the abuse. The deficiency was identified during a review of medical records, staff and resident interviews, and facility self-reported incidents, which confirmed that the required immediate reporting procedures were not followed by the staff involved.
Failure to Implement Effective Infection Control Procedures During GI Outbreak
Penalty
Summary
The facility failed to develop and implement effective infection control procedures, which included timely reporting of potentially communicable diseases to the local Health Department. This deficiency was identified during a gastrointestinal illness (GI) outbreak that affected 13 residents and potentially all residents in the facility. The Director of Nursing (DON) and the Infection Control Preventionist (ICP) did not track the residents and employees who developed GI-related symptoms as part of their infection surveillance plan. The outbreak began on February 12, 2025, and involved multiple residents and staff members who called off due to illness. Interviews with the DON and ICP confirmed that the residents and employees with GI symptoms were not recorded on the infection control surveillance log. The DON admitted that they could not keep track of the residents who had symptoms, and the employees who called off sick were not being tracked according to the infection control surveillance plan. The facility's failure to notify the local Health Department in a timely manner was also verified by the DON, who noted that they were notifying the residents' families of the outbreak. The facility's policy on infection surveillance, as well as CDC and Ohio Department of Health guidance, emphasize the importance of notifying appropriate health authorities in the event of an outbreak. However, the facility did not adhere to these guidelines, as confirmed by the County Health Department Nurse, who stated that their department had not received any information about the GI virus outbreak. The Nurse Practitioner was only notified of the outbreak after several residents had already developed symptoms, and a protocol for managing nausea, vomiting, and diarrhea was initiated late. This lack of timely reporting and tracking contributed to the deficiency in infection control procedures.
Failure to Notify Physician of Elevated Blood Pressure
Penalty
Summary
The facility failed to notify the physician or non-physician practitioner (NPP) of significant changes in the health status of three residents, specifically regarding elevated blood pressure readings. Resident #05, who was admitted with multiple diagnoses including obstructive hypertrophic cardiomyopathy, Alzheimer's disease, and hypertension, had several instances of elevated blood pressure readings documented over a period from June to October 2024. Despite these elevated readings, there was no documentation indicating that the physician or NPP was notified, as required by the facility's protocol and policy. The facility's protocol stated that if a resident's systolic blood pressure exceeded 180 mm/Hg, staff should assess for symptoms such as shortness of breath or chest pain and notify a physician. Additionally, the facility's policy required notification of significant changes in a resident's health status within one business day. An interview with the Regional Clinical Nurse confirmed the lack of notifications for the elevated blood pressure readings. This deficiency affected the care of Resident #05, who was severely cognitively impaired, as indicated by a Brief Interview of Mental Status (BIMS) score of 01.
Failure to Issue ABN After NOMNC
Penalty
Summary
The facility failed to issue an Advanced Beneficiary Notice (ABN) to a resident when a Notice of Medicare Non-Coverage (NOMNC) was issued, and the resident did not discharge. This deficiency affected one resident who was admitted with acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease with acute exacerbation, and anemia. The NOMNC indicated that the last covered day was January 7, 2025, and the resident signed the NOMNC on January 3, 2025. However, there was no documentation that the resident was notified of the last covered date or the cost to remain in the facility for the days following the last covered date. The resident was listed as private pay on January 8 and 9, 2025, and later applied for veterans' benefits. The Business Office Manager confirmed that an ABN or cost information was not provided to the resident, and the facility lacked a policy on issuing an ABN.
Failure to Maintain a Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by the conditions observed in the rooms of three residents. Resident #13, who had impaired cognition and was dependent on staff for activities of daily living, was found to have a soiled bed with stains, food crumbs, and a severely worn mattress that dipped inward. The room also had a broken light switch with sharp pieces sticking out and a dirty windowsill with an unknown sticky substance. Resident #13 communicated the need for a new mattress and assistance to be repositioned in bed due to sliding into the mattress's sunken middle. Resident #64, who had mildly impaired cognition and was also dependent on staff, had a bathroom with a dusty, soiled, and slippery floor, along with an unknown brown chunky substance around the toilet. The resident reported a recent fall due to the slick floor. Housekeeping staff confirmed the unclean conditions and were unable to verify when the bathroom was last cleaned. Resident #08, who was cognitively intact and dependent on staff, had a sticky fly strip over her bed with multiple dead flies, which she had requested due to a fly infestation in her room. The presence of the fly strip was confirmed by both the resident and housekeeping staff. The facility's Routine Housekeeping Policy, which mandates routine cleaning and disinfection, was not adhered to, resulting in these deficiencies.
Failure to Complete PASRR for Residents Admitted to Hospice
Penalty
Summary
The facility failed to complete a Pre Admission Screening and Resident Review (PASRR) following a significant change in condition for two residents. Resident #10, who was admitted to the facility with multiple diagnoses including schizophrenia, bipolar disorder, and dementia, was admitted to hospice care on 04/23/24. Despite this significant change, no PASRR was completed. The Minimum Data Set (MDS) indicated that Resident #10 was cognitively impaired, and the facility's social worker confirmed the oversight. Similarly, Resident #41, with diagnoses such as dementia and metabolic encephalopathy, was admitted to hospice care on 11/05/24 without a corresponding PASRR. The MDS assessment showed impaired cognition, and the regional clinical nurse verified the failure to conduct a PASRR review. These deficiencies were identified through record reviews and staff interviews, affecting the facility's compliance with regulatory requirements.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that residents were provided with quarterly care conferences, affecting two residents. Resident #08, who was admitted with multiple diagnoses including tachycardia, obstructive sleep apnea, and major depressive disorder, did not have documented care conferences for two of the four quarters in the past year. Despite being cognitively intact and dependent on staff for activities of daily living, the resident's care conferences were only documented on two occasions, as verified by the social worker. Similarly, Resident #64, who was admitted with diagnoses such as dementia and schizoaffective disorder, did not have quarterly care conferences documented for the past year. The resident, who had mildly impaired cognition and was dependent on staff for ADLs, did not recall attending any care conferences. The social worker confirmed the absence of scheduled care conferences for this resident, indicating a lapse in the facility's adherence to care planning protocols.
Failure to Change Suprapubic Catheter as Ordered
Penalty
Summary
The facility failed to ensure that a resident's suprapubic urinary catheter was changed according to physician orders. The resident, who was severely cognitively impaired and had a history of dementia, hydronephrosis with renal and urethral calculous obstruction, calculus of gall bladder without obstruction, and chronic kidney failure, was admitted with a suprapubic catheter due to obstructive uropathy. The physician's order required the catheter to be changed every four weeks and as needed. However, the catheter was not changed as scheduled on February 14, 2025, as indicated in the Treatment Administration Record (TAR). The Director of Nursing (DON) confirmed that the catheter change was missed and that the nurse responsible did not provide a reason for the oversight. The facility lacked a specific policy on following physician's orders related to catheter care, relying instead on standard nursing practices. The Acting Administrator acknowledged the absence of such a policy. The resident was noted to be prone to infections, which underscores the importance of adhering to the prescribed catheter change schedule.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered, specifically Midodrine, which was prescribed for hypotension. The resident, who was cognitively impaired, had a complex medical history including obstructive hypertrophic cardiomyopathy, Alzheimer's disease, and chronic kidney disease. The physician's order specified that Midodrine should be held if the resident's systolic blood pressure was above 120 mm/Hg. However, the medication was administered on multiple occasions when the resident's systolic blood pressure exceeded this threshold, indicating a failure to adhere to the prescribed parameters. The review of the Medication Administration Records (MARs) for the resident revealed several instances where Midodrine was either incorrectly administered or held, contrary to the physician's orders. Interviews with facility staff confirmed these discrepancies. The facility's policy and standing orders were clear about the administration parameters for Midodrine, yet these were not consistently followed, leading to the deficiency. The facility's failure to comply with the medication administration guidelines as per the physician's orders and standing orders resulted in the resident not receiving the appropriate pharmaceutical care.
Improper Medication Storage for a Resident
Penalty
Summary
The facility failed to ensure proper storage of medications for a resident, which was identified during an observation. Resident #26, who was cognitively impaired and dependent on staff for medication administration, was found to have a half-full bottle of over-the-counter Pepto Bismol on his bedside table. This observation was made in the presence of an LPN and a CNA, who confirmed that the resident was not permitted to have medications at his bedside and that all medications were to be administered by facility staff. The resident admitted to having the Pepto Bismol at his bedside because he felt nauseated the previous day. This incident highlights a lapse in the facility's adherence to medication storage protocols, affecting one resident out of the three reviewed in a facility with a census of 88.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, which affected a resident and had the potential to impact all residents on the 200 unit. Resident #13, who had diagnoses including anemia, heart failure, hypertension, diabetes mellitus, and aphasia, was found in a room with active gnats flying around his bed. The bed was observed to be soiled and had food crumbs, which was verified by a Certified Nursing Assistant. This indicates a lack of cleanliness and pest control in the resident's immediate environment. Additionally, the dining room on the 200-hallway was observed to have a breakfast tray and juice containers left out, with the area soiled with food debris. Ants were seen crawling around the sink and cabinet area, which was confirmed by a Licensed Practical Nurse and a Housekeeper. The Environmental Service Director acknowledged the issue with active ants but did not complete the interview. The facility's pest control policy, dated 10/10, stated that the building should be kept free of insects and rodents, yet the observations indicated a failure to adhere to this policy.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its abuse policies effectively, resulting in a deficiency related to the reporting of an alleged abuse incident involving two residents. Resident #25, who has severe cognitive impairment and multiple health conditions, was allegedly kissed by Resident #36, who also has severe cognitive impairment and behavioral disturbances. The incident was witnessed by STNA #60, who did not report the event to the Administrator or Director of Nursing as required by the facility's policy. Instead, STNA #60 mentioned the incident to other staff members, but it appears that the report was not clearly communicated or acted upon by the LPNs present at the time. The facility's policy mandates immediate reporting of all abuse allegations to the Executive Director/Administrator, but this protocol was not followed. The Administrator confirmed that STNA #60 did not report the incident as required. The facility's investigation revealed that the contact information for reporting such incidents was available to all staff, indicating a failure in adherence to established procedures. This deficiency was identified during a complaint investigation, highlighting a lapse in the facility's internal communication and reporting processes regarding abuse allegations.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report allegations of abuse involving Resident #25, who was admitted to the skilled living facility with multiple diagnoses including dementia and severe cognitive impairment. An incident occurred where Resident #36, who also had severe cognitive impairment, was witnessed by STNA #60 kissing Resident #25. Despite witnessing the incident, STNA #60 did not report it to the Administrator or Director of Nursing as required by the facility's policy. The incident was only reported to the Administrator on 06/06/24, three days after it occurred, when STNA #73 informed them. Interviews with various staff members revealed that STNA #60 claimed to have informed LPNs #80, #90, and #50 about the incident, but none of them acknowledged receiving such a report. Additionally, Resident #25 denied any unwanted contact during an interview, and Resident #36 also denied the incident. The facility's policy mandates immediate reporting of such allegations to the Executive Director/Administrator, which was not adhered to in this case, leading to a deficiency in the facility's handling of the situation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 506 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fairborn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wright Rehabilitation And Healthcare Center | 1.5 mi | ★★★★★ | 10 | 0 |
| Dayspring Of Miami Valley Hlth Care Center & Rehab | 1.8 mi | ★★★★★ | 0 | 0 |
| Friends Extended Care Center | 5.1 mi | ★★★★★ | 10 | 0 |
| Beavercreek Post Acute | 7.5 mi | ★★★★★ | 0 | 0 |
| Vancrest Of New Carlisle | 8.4 mi | ★★★★★ | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Trinity Community At Fairborn.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.