Inspection·August 1, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, medical record review, staff and resident interviews, and policy review, the facility failed to ensure a resident's urine collection bag was covered with a privacy bag. This affected one (#13) of one resident observed with an indwelling catheter and an urine collection bag. The facility identified three (#13, #14, and #15) residents with indwelling catheters. The facility census was 78. Findings include: Review of the medical record for Resident #13 revealed an admission date of 02/07/20, with medical diagnoses of dementia, conversion disorder with seizures, neuromuscular dysfunction of bladder, and hypertension. Review of the medical record for Resident #13 revealed a quarterly Minimum Data Set (MDS) assessment, dated 07/15/24, which indicated Resident #13 had severe cognitive impairment, was dependent upon staff for toilet hygiene, and had an indwelling catheter in place. Review of Resident #13's physician orders revealed a physician order dated 07/09/24, for skilled nursing to exchange 16 French suprapubic tube monthly and to flush suprapubic catheter with 20 cubic centimeters (cc) of sterile saline daily and as needed. Observation with interview on 08/01/24 at 7:53 A.M., with Resident #13 revealed he was wheeling himself down the hall with an urine collection bag hanging off the side of his wheelchair with urine visible. The urine collection bag was not covered by a privacy bag. Interview with Resident #13, at the time of the observation, stated he did not like having his urine visible to everyone. Resident #13 stated the staff had assisted him with the transfer into the wheelchair and hooked the urine collection bag onto his wheelchair. Interview on 08/01/24 at 7:56 A.M., with State Tested Nursing Assistant (STNA) #68 confirmed Resident #13 was in the hallway, his urine collection bag was not covered by a privacy bag, and urine was visible to staff, residents and visitors. Review of the policy titled, Dignity, revised in April 2018, stated the facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The policy continued to state that maintaining a resident's dignity should include refraining from practices that would be demeaning to residents such as leaving urinary catheter bags uncovered. (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 08/01/2024 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)