Health inspection·June 4, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on medical record review, observation, resident interview, and staff interview the facility failed to ensure the building and furnishings were in good repair. This affected Resident #43 and the 19 residents residing in the in the 300/400 hall (#2, #3, #8, #10, #11, #14, #18, #21, #23, #28, #32, #37, #39, #41, #42, #43, #44, #45, and #46). The facility census was 47 residents. Findings include: 1.Review of the medical record for Resident #43 revealed an admission date of 02/17/25 with diagnoses including chronic obstructive pulmonary disease and bipolar disorder. Review of the Minimum Data Set (MDS) assessment for Resident #43 dated 05/21/25 revealed the resident had intact cognition and required assistance with activities of daily living (ADLs). Observation on 06/04/25 at 9:10 A.M. of Resident #43's room revealed there was a hole in the wall approximately 18 inches above the baseboard which measured approximately nine inches in diameter. Interview on 06/04/25 at 9:10 A.M. with Resident #43 confirmed the hole in his wall had been there when he was admitted to the facility in February 2025. Resident #43 confirmed he asked facility staff if they would repair the hole, but it had not yet been repaired. Resident #43 confirmed overall the facility was in poor repair. Interview on 06/05/25 at 9:25 A.M. with Licensed Practical Nurse (LPN) # 605 confirmed there was a hole in the wall of Resident #43's room which should be repaired. Interview on 06/04/25 at 3:40 P.M. with the Administrator confirmed there was a hole in the wall of Resident #43's room which was caused by a power wheelchair. 3. Observation on 06/04/25 at 10:00 A.M. of the resident lounge area near the 400 hall revealed a built-in buffet cabinet which measured approximately 12 feet in length. Each end of the buffet had open areas below the counter measuring approximately three feet in diameter. There were missing baseboards, chipped wood, and multiple scuff marks to the buffet cabinet. Further observation revealed the drawers in the center of the buffet area were cracked and off-center. Interview on 06/04/25 at 10:00 A.M. with LPN #605 confirmed the built-in buffet area in the resident lounge was not in good repair and the cabinets looked like they were moldy. Interview on 06/05/25 at 10:48 A.M. with Maintenance Director (MD) #510 confirmed the cabinets (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: 365364 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 365364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Court Nursing and Rehabilitation Center 4911 Covenant House Drive 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)