Fairborn, OH

Trinity Community At Fairborn

4-star overall rating with 3-star inspections with 14 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

789 Stoneybrook Trail, Fairborn, OH

(937) 878-0262

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

United Church Homes

Operator or chain grouping

Approved since

1994-08-31

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

6 facilities

Chain averages 3 overall / 3 health / 3 staffing / 5 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.48

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

0.97

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.60

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

4.06

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.45

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

3.68

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.18

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.47

CMS adjusted RN staffing hours

Adjusted total hours

3.99

CMS adjusted total nurse staffing hours

Case-mix index

1.39

Higher values indicate more complex resident acuity

RN turnover

63%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

51%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,668

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

32.11

Composite VBP score used to determine payment impact.

Payment multiplier

0.9869

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.07

Baseline 23.46% · Performance 20.52% · Measure score 4.07 · Achievement 1.96 · Improvement 4.07

Healthcare-associated infections

Baseline 8.65% · Performance 9.09% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

6.57

Baseline 75.90% · Performance 39.78% · Measure score 6.57 · Achievement 5.85 · Improvement 6.57

Adjusted total nurse staffing

2.20

Baseline 3.78 hours · Performance 3.70 hours · Measure score 2.20 · Achievement 2.20 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.9%	10.72% 0.2 pts worse	No Different than the National Rate · Eligible stays 66 · Observed rate 13.64% · Lower 95% interval 6.95%
Discharge to community	48.99%	50.57% 1.6 pts worse	No Different than the National Rate · Eligible stays 63 · Observed rate 36.51% · Lower 95% interval 35.93%
Medicare spending per beneficiary	0.95	1.02 0.1 pts better
Drug regimen review with follow-up	94.34%	95.27% 0.9 pts worse	Numerator 50 · Denominator 53
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 53
Discharge self-care score	39.47%	53.69% 14.2 pts worse	Numerator 15 · Denominator 38
Discharge mobility score	57.89%	50.94% 7 pts better	Numerator 22 · Denominator 38
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 53 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	9.09%	7.12% 2 pts worse	No Different than the National Rate · Eligible stays 56 · Observed rate 16.07% · Lower 95% interval 5.03%
Staff COVID-19 vaccination coverage	1.55%	8.2% 6.6 pts worse	Numerator 2 · Denominator 129
Staff flu vaccination coverage	39.53%	42% 2.5 pts worse	Numerator 51 · Denominator 129
Discharge function score	47.37%	56.45% 9.1 pts worse	Numerator 18 · Denominator 38
Transfer of health information to provider	85%	95.95% 11 pts worse	Numerator 17 · Denominator 20
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	8.7%	25.2% 16.5 pts worse	Numerator 2 · Denominator 23

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	79.3%	92.4% 13.1 pts worse	93.4% 14.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 81.7% · Q2 78.7% · Q3 75.0% · Q4 81.8% · 4Q avg 79.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	91.5%	94.5% 3 pts worse	95.5% 4 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 91.5%
Percentage of long-stay residents experiencing one or more falls with major injury	6.0%	3.3% 2.7 pts worse	3.3% 2.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 6.7% · Q3 6.6% · Q4 3.9% · 4Q avg 6.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	3.7%	26.1% 22.4 pts better	11.4% 7.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 5.5% · Q3 3.2% · Q4 0.0% · 4Q avg 3.7%
Percentage of long-stay residents who lose too much weight	5.7%	6.2% 0.5 pts better	5.4% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 11.3% · Q3 4.8% · Q4 0.0% · 4Q avg 5.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	23.6%	25.4% 1.8 pts better	19.6% 4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 25.4% · Q3 23.4% · Q4 23.4% · 4Q avg 23.6%
Percentage of long-stay residents who received an antipsychotic medication	9.5%	11.5% 2 pts better	16.7% 7.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 12.2% · Q3 4.0% · Q4 6.1% · 4Q avg 9.5% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	7.4%	7.7% 0.3 pts better	16.3% 8.9 pts better	Long Stay · 2024Q4-2025Q3 · Q2 4.3% · Q3 11.1% · Q4 8.0% · 4Q avg 7.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	6.6%	6.2% 0.4 pts worse	14.9% 8.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 15.0% · Q4 6.7% · 4Q avg 6.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	0.2% 0.2 pts worse	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.7%	0.5% 0.2 pts worse	1.7% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	26.4%	21.7% 4.7 pts worse	19.8% 6.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 28.8% · Q3 18.0% · Q4 32.8% · 4Q avg 26.4%
Percentage of long-stay residents with pressure ulcers	5.1%	3.7% 1.4 pts worse	5.1% About the same	Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 9.5% · Q3 3.2% · Q4 1.0% · 4Q avg 5.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	18.6%	78.1% 59.5 pts worse	81.7% 63.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 19.4% · Q3 18.8% · Q4 16.7% · 4Q avg 18.6%
Percentage of short-stay residents who had an outpatient emergency department visit	5.0%	12.5% 7.5 pts better	12.0% 7 pts better	Short Stay · 20240701-20250630 · Adjusted 5.0% · Observed 5.3% · Expected 11.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.6%	1.2% 0.6 pts better	1.6% 1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	59.2%	75.6% 16.4 pts worse	79.7% 20.5 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 59.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	13.1%	25.1% 12 pts better	23.9% 10.8 pts better	Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 15.8% · Expected 28.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-25 · Fire 2025-02-25

14 health deficiencies

Top issue: Resident Rights (3 deficiencies)

5 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Cycle 2 Health 2022-01-12 · Fire 2022-01-12

14 health deficiencies

Top issue: Resident Rights (4 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2019-05-16 · Fire 2019-05-16

8 health deficiencies

Top issue: Resident Rights (3 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-25

K343 · Smoke Deficiencies

Fire Safety

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

Corrected 2025-03-31

F · Potential for more than minimal harm 2025-02-25

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-03-31

F · Potential for more than minimal harm 2025-02-25

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-03-31

F · Potential for more than minimal harm 2025-02-25

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-03-31

E · Potential for more than minimal harm 2025-02-25

K344 · Smoke Deficiencies

Fire Safety

Have an alternate power supply for its alarm system.

Corrected 2025-03-31

F · Potential for more than minimal harm 2022-01-12

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2022-03-11

F · Potential for more than minimal harm 2022-01-12

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-03-11

F · Potential for more than minimal harm 2022-01-12

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-03-11

F · Potential for more than minimal harm 2022-01-12

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-03-11

F · Potential for more than minimal harm 2022-01-12

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2022-03-11

F · Potential for more than minimal harm 2022-01-12

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2022-03-11

E · Potential for more than minimal harm 2022-01-12

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2022-03-11

F · Potential for more than minimal harm 2019-05-16

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2019-07-04

F · Potential for more than minimal harm 2019-05-16

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2019-07-04

F · Potential for more than minimal harm 2019-05-16

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2019-07-04

F · Potential for more than minimal harm 2019-05-16

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2019-07-04

E · Potential for more than minimal harm 2019-05-16

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2019-07-04

C · Minimal harm 2019-05-16

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2019-07-04

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-07-31

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2025-08-15

D · Potential for more than minimal harm 2025-07-31

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2025-08-15

D · Potential for more than minimal harm 2025-06-03

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-06-03

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-04-04

F · Potential for more than minimal harm 2025-02-25

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-31

D · Potential for more than minimal harm 2025-02-25

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-03-31

D · Potential for more than minimal harm 2025-02-25

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2025-03-31

D · Potential for more than minimal harm 2025-02-25

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-03-31

D · Potential for more than minimal harm 2025-02-25

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2025-03-31

D · Potential for more than minimal harm 2025-02-25

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2025-03-31

D · Potential for more than minimal harm 2025-02-25

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-03-31

D · Potential for more than minimal harm 2025-02-25

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-03-31

D · Potential for more than minimal harm 2025-02-25

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-03-31

D · Potential for more than minimal harm 2025-02-25

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2025-03-31

D · Potential for more than minimal harm 2024-06-11

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-07-08

D · Potential for more than minimal harm 2024-06-11

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-07-08

D · Potential for more than minimal harm 2024-03-04

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-03-07

D · Potential for more than minimal harm 2024-03-04

F620 · Resident Rights Deficiencies

Health

Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.

Corrected 2024-03-07

E · Potential for more than minimal harm 2022-01-12