Health inspection·June 30, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, and review of a medical record, the facility failed to maintain flooring in resident rooms in a safe and homelike manner. This affected one (#17) of seven residents reviewed for environment. The facility census was 68 Findings include: Review of the medical record for Resident #17 revealed an admission date of 01/05/24 with diagnoses of acute encephalopathy, pressure ulcer of both feet, stage three (full-thickness skin loss), and sepsis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact, required set-up assistance for eating, supervision assistance for oral hygiene, toileting hygiene, and wheelchair mobility, and required partial assistance for bathing, dressing, personal hygiene, bed mobility, and transfers. Observation on 06/25/24 at 11:00 A.M. of Resident #17's bedroom noted two areas of missing flooring by the foot of the bed measuring approximately three inches long by six inches wide by 0.5 inches deep. There was also a seam down the middle of the floor with missing flooring measuring approximately 10 inches long by 1.5 inches wide by 0.5 inches deep. Interview with Resident #17 on 06/25/24 at 11:00 A.M. confirmed the two areas missing flooring and the seam in the middle of the floor, and stated the floor was missing since his admission to the room. Resident #17 stated he assumed there was some kind of equipment that sat in the area previous which caused the damage to the floor. Interview on 06/25/24 at 2:28 P.M. with Licensed Practical Nurse (LPN) #200 confirmed the floor in Resident #17's room had two areas of missing flooring measuring approximately three inches long by six inches wide by 0.5 inches deep and also a seam down the middle of the floor with missing flooring measuring approximately 10 inches long by 1.5 inches wide by 0.5 inches deep. LPN #200 also confirmed the areas of the floor had been damaged since Resident #17 was admitted and that the areas with missing flooring seemed moist and was peeling back. Interview on 06/25/24 at 3:01 P.M. with Maintenance Assistant (MA) #201 confirmed the two areas of missing flooring and the seam down the middle of the floor in Resident #17's room. MA #201 also confirmed the areas where the flooring was missing were moist and peeling back. (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 2 Event ID: 365309 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 365309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Trotwood LLC 5790 Denlinger Road Dayton, OH 45426 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)