Inspection·October 22, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to develop a comprehensive person-centered care plan for a resident who developed pressure ulcers while residing in the facility. This affected one (#30) out of the three residents reviewed for pressure ulcer care and services. The facility census was 68. Findings include: Review of the medical record for the Resident #30 revealed an admission date of 08/31/24 with medical diagnoses of metabolic encephalopathy, diabetes mellitus, history of cerebral infarction, dysphagia, hypertension, and hypothyroidism. Review of the medical record revealed a discharge date of 10/16/24. Review of the medical record for Resident #30 revealed an admission Minimum Data Set (MDS) assessment, dated 09/09/24, which indicated Resident #30 had moderate cognitive impairment. The MDS indicated Resident #30 required supervision/touching assistance with eating and was dependent upon staff for toilet hygiene and transfers and required substantial/maximum assistance for bathing and bed mobility. The MDS revealed Resident #30 was always incontinent of bladder and bowel, was at risk for skin breakdown, and did not have any skin breakdown present upon admission. Review of the medical record for Resident #30 revealed a skin assessment, dated 10/01/24, for an unstageable pressure ulcer to mid-sacrum which was first observed on 09/30/24. The measurements were 3 centimeters (cm) by 2.5 cm by 1 cm with 100% slough present and no tunneling noted. The assessment indicated a treatment was ordered, family was notified, and interventions in place included pressure relieving cushion to bed and chair, wound care, turn and reposition every two hours and as needed, daily skin checks by Certified Nursing Assistant (CNA) and off-loading. Review of the skin assessment, dated 10/15/24, revealed the unstageable pressure ulcer to mid-sacrum measured 13 cm by 5.5 cm prior to debridement and had 100% slough. The skin assessment noted the wound had worsened and had an odor and large amount of purulent drainage. The skin assessment also revealed a deep tissue injury (DTI) to right buttock which measured 5.5 cm by 2.0 cm with 100% necrotic tissue and a DTI to left buttock which measured 6 cm by 2 cm with 100% necrotic tissue. Review of the medical record for Resident #30 revealed a physician order dated 09/30/24 for low air loss mattress, and an order dated 10/02/24 to cleanse mid-sacral wound with normal saline, apply Santyl, nickel thick layer, cover with moist gauze and cover with dry clean dressing daily and as needed which was discontinued on 10/08/24. Review of the orders revealed an order dated 10/08/24 to cleanse mid-sacral wound with normal saline, apply Santyl, nickel thick layer, cover with moist gauze (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 3 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 10/22/2024 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)