Health inspection·August 14, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interviews, review of self-reported incidents (SRIs) and policy review, the facility failed to thoroughly investigate an allegation of misappropriation. This affected one (#51) resident of the three residents reviewed for misappropriation. The facility census was 79. Residents Affected - Few Findings include: Review of the medical record for Resident #51 revealed an admission date of 03/14/24. Diagnoses included chronic obstructive pulmonary disease (COPD), dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #51 was cognitively intact. Review of the facility's SRI dated 07/26/24 at 2:23 P.M., revealed Resident #52's relative stole a check from Resident #51 and cashed it. Resident #51 reported Resident #52 had a niece that wrote a check out to Resident #52's account. Resident #51 was assisted to the bank to file a fraud claim and called the police to file a report. Resident #52''s niece had been in Resident #51's room helping the resident write out checks because her handwriting was not the best and Resident #51 was signing the checks. Resident #52 was interviewed and was not aware of anything. The SRI was substantiated for misappropriation, verified by evidence and the suspected abuser was prohibited from entering the community until the matter was resolved. The police were notified, and a bank grievance was completed to get reimbursement. Interview with the Administrator on 08/13/24 at 2:00 P.M., revealed the facility was notified of allegations of misappropriation on 07/26/24 by Resident #51. The Administrator stated one of Resident #51's personal checks went missing and it was discovered being cashed for $200.00 in Resident #52's name. Resident#51 reported Resident #52's niece had been assisting her with writing checks because her writing is not the best and stated the niece must have taken the check. The Administrator stated Resident #51 was assisted to the bank to file a fraud alert and called the police to file a theft report. Interview with Resident #51 on 08/13/24 at 2:45 P.M., revealed on 07/26/24 she reported to the facility staff that a $200.00 check had been cashed in her roommate's (Resident #52) name. The resident stated she did not authorize the check to be written to Resident #52. Resident #51 stated the facility took her to the bank on 07/26/24 and she filed a fraud report, and then a police report alleging Resident #52's niece as the suspect. Resident #51 stated Resident #52's niece had been assisting her with writing checks recently due to her handwriting not being the best and the niece made a check (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 08/14/2024 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)