Arc at Trotwood LLC

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to notify resident guardians of new physician's orders. The affected one (Resident #59) of three residents reviewed for participation in care planning. The facility census was 99 residents.

Inspectors wroteBased on medical record review, review of the facility investigation, review of the Self-Reported Incident (SRI), staff interview, and policy review, the facility failed to timely report an allegation of neglect to the state agency. This affected one (Resident #59) of three residents reviewed for elopement. The facility census was 99 residents.

Inspectors wroteBased on medical record review, staff interview, physician interview, and policy review, the facility failed to transcribe and implement physician orders in a timely manner. This affected one (Resident #102) of three residents reviewed for change in condition. The facility census was 99 residents.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure residents received adequate supervision and failed to ensure failed to provide the appropriate level of assistance during resident transfers . This affected two (Residents #59 and #103) of three residents reviewed for accidents and hazards. The facility census was 99 residents.

Inspectors wroteBased on medical record review, review of the facility investigation, review of the Self-Reported Incident (SRI), staff interview, and policy review, the facility failed to ensure medical records were accurate and complete. This affected one (Resident #59) of three residents reviewed for documentation. The facility census was 99 residents.

Inspectors wroteBased on observations and staff interview, the facility failed to ensure kitchen was kept in a clean and sanitary manner. This had the potential to affect all the residents who received trays from the kitchen, the facility identified two residents (#108 and #125) who did not receive meal trays. The facility census was 102.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure an Automated External Defibrillator (AED) device had new pads available for use in the event of a medical emergency. This had the affect on 18 out 19 residents the facility identified as a full code on the Rehab Hall. The census was 102.

Inspectors wroteBased on medical record, staff interview, and policy review, the facility failed to notify family of a resident's change of condition and/or regarding new physician orders. This affected one (#114) out of three residents reviewed for change of condition. The facility census was 102.

Inspectors wroteBased on medical record reviews, staff and resident interviews, and policy review, the facility failed to ensure baths/showers were offered or completed as scheduled. This affected two (#85 and #112) out of three residents reviewed for activities of daily living (ADLs). The facility census was 102.

Inspectors wroteBased on medical record reviews, observation, staff and resident interviews, review of facility incident/accident log, and policy and procedure review, the facility failed to ensure smoking/vaping devices were properly secured and not at bedside. This affected one (#85) out of three residents reviewed for smoking. The facility also failed to ensure a resident's fall was investigated and interventions were implemented and failed to ensure neurological checks were completed after a unwitnessed falls. This affected one (#115) out of three residents reviewed for falls. The facility census was 102.

Inspectors wroteBased on medical record review, staff and resident interviews, and policy review, the facility failed to administer medications as per physician orders. This affected one (#112) out of three residents reviewed for medication administration. The facility census was 102.

Inspectors wroteBased on medical record review, staff interviews, and policy review, the facility failed to administer insulin as ordered and to ensure blood pressure medications were administered per the ordered parameters resulting in significant medication errors. This affected one (#64) out of three residents reviewed for medications. The facility census was 102.

Inspectors wroteBased on observation, interview, medical record and facility policy review, the facility failed to securely store medications. This affected one resident (#57) of five reviewed for medication administration. The facility census was 89.

Inspectors wroteBased on observation, interview, medical record and facility policy review, the facility failed to ensure the medical record was accurate. The facility documented medication as administered by facility staff when it was self-administered by the resident without nursing supervision. This affected one resident (#57) of five reviewed for medication administration. The facility census was 89. Findings Include:Review of the medical record for Resident #57 revealed an admission date of 01/22/25 with diagnoses including but not limited to dysphagia following cerebral infarction, type two diabetes, hemiplegia and hemiparesis affected the non-dominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #57 revealed an intact cognition. Resident #57 required set up assistance for eating. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medications were administered in a way to avoid cross contamination. This affected one resident (#86) of five residents observed during medication administration. The Facility census was 89. Findings Include: Medical record review for Resident #86 revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease, epilepsy, and nontraumatic intracerebral hemorrhage. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #86 dated 08/12/25 revealed intact cognition. Resident #86 required set up assistance to moderate assistance for activities of daily living. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify residents that the amount of funds in their accounts was 200 dollars less than the Medicaid resource limit and that the residents may lose eligibility for Medicaid. This affected six (#10, #43, #5, #29, #27 and #11) out of seven residents reviewed for personal funds. The facility census was 97.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 92 days of the prior MDS assessment for 1 (Resident #49) of 9 residents reviewed for the resident assessment task. In addition, the facility failed to ensure quarterly MDS assessments were signed as complete within 14 days of the Assessment Reference Date (ARD) for 3 (Residents #4, #34, and #46) of 9 residents reviewed for the resident assessment task.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to resolve a concern in a timely manner for 1 (Resident #66) of 2 residents reviewed for grievances. In addition, the facility failed to document concerns, ensure resolution, and provide feedback for 1 (Resident #57) of 2 residents reviewed for grievances.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded related to the use of a non-invasive mechanical ventilator for 1 (Resident #57) of 2 residents reviewed for respiratory services.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) accurately reflected all diagnosed mental disorders and prescribed psychotropic medications for 2 (Resident #16 and Resident #92) of 4 residents reviewed for PASARR requirements.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff documented the administration of medications in accordance with acceptable standards of practice. Specifically, staff documented the administration of medication prior to actually administering the medication for 1 (Resident #57) of 4 residents observed during medication administration.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff checked for incontinence every two hours and provided incontinence care when indicated for 1 (Resident #57) 1 sampled resident reviewed for urinary tract infections. Specifically, during the dayshift on 05/15/2025, Resident #57 was not checked for incontinence or provided incontinence care until 10:40 AM.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide residents with food at an appetizing temperature for 1 (Resident #5) of 20 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents' medical records were accurate and complete for 2 (Resident #57 and Resident #204) of 22 sampled residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medications were administered in a way to avoid transmission of communicable diseases and infections. Specifically, facility staff touched resident medications with their bare hands when administering medication, which affected 2 (Resident #20 and Resident #57) of 4 residents observed during medication administration.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review, observations and staff interview, the facility failed to follow infection control procedures while performing wound care. This affected one (#11) out of three residents reviewed for infection control. The facility census was 68.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, staff interview, and review of the facility policy the facility failed to maintain mechanical equipment in a safe operating condition. This had the potential to affect all residents residing in the facility. The facility census was 76.

Inspectors wroteBased on observation, staff interview, review of the facility policy, and review of Material Safety Data Sheets (MSDS), the facility failed to store, prepare, and distribute food in a sanitary manner. This had the potential to affect 75 residents residing at the facility. The facility identified one (Resident #50) who did not receive food from the facility kitchen. The facility census was 76.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to timely a assess and treat resident injuries following falls. This affected one (Resident #67) resident of three residents reviewed for falls. The facility census was 76 residents.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to adequately assess and treat resident pain following a fall. This affected one (Resident #67) of three residents reviewed for falls. The facility census was 76.

Inspectors wroteBased on record review, observation, staff interview, and review of the facility policy, the facility failed to provide adequate incontinence care in a sanitary manner. This affected one (Resident #13) of three residents reviewed for incontinence care. The facility census was 76.

Inspectors wroteBased on medical record reviews, staff interviews, and policy review, the facility failed to assess a resident's fall risk upon admission to the facility. This affected two (#5 and #84) out of three residents reviewed for falls. The facility census was 81.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to provide a safe and homelike environment. This affected one (#27) resident out of the three residents reviewed for environment. The facility census was 81.

Inspectors wroteBased on record review, and staff and physician interviews, the facility failed to ensure non-pressure ulcer skin conditions were appropriately assessed and monitored. Additionally, the facility failed to ensure treatments were implemented for non-pressure ulcer skin conditions. This affected one (#9) out of three residents reviewed for wounds. The facility census was 86.

Inspectors wroteBased on record review, staff interviews and review of medication information from Medscape, the facility failed to ensure insulin was administered as physician ordered resulting in significant medication errors. This affected two (#16 and #40) out of three residents reviewed for medication administration. The facility census was 86.

Inspectors wroteBased on medical record review, observations, staff and resident interviews and policy review, the facility failed to ensure residents were given routine showers/bathes for three (#86, #88, and #114) residents out of four residents reviewed for showers/bathes. Additionally, the facility failed to ensure fingernail care was completed for one (#86) resident out of the four reviewed for fingernail care. The facility census was 77.

Inspectors wroteBased on medical record review and staff and resident interviews, the facility failed to ensure medications were administered as ordered. This affected two (#94 and #114) out of the four residents reviewed for medication administration. The facility census was 77.

Inspectors wroteBased on review of facility time punches and staff interview, the facility failed to ensure Registered Nurse (RN) coverage was provided for at least eight hours a day, seven days a week. This had the potential to affect all 61 residents at the facility. The facility census was 61.

Inspectors wroteBased on staff interview and personnel file review, the facility failed to complete annual performance evaluations for State Tested Nursing Assistants (STNA). This affected two (STNA #155 and #190) out of three STNA's reviewed who were employed at the facility for longer than one year. This had the potential to affect all 61 residents at the facility. The facility census was 61.

Inspectors wroteBased on review of a staff roster and staff interview, the facility failed to ensure a full-time Licensed Social Worker was employed on a full-time basis. This had the potential to affect all 61 residents residing in the facility. The facility census was 61.

Inspectors wrote3. Review of the medical record for Resident #68 revealed he was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. He was re-admitted to the facility on [DATE]. Diagnoses included vascular dementia with behavioral disturbance, type two diabetes mellitus without complications, and cerebral infarction. Review of the significant change MDS assessment, dated 05/10/22, revealed Resident #68 had severely impaired cognition. Review of the nursing progress note dated 05/21/22 revealed Resident #68 was sent to the hospital for further evaluation following a fall. Review of the facility form titled Notice of Resident Transfer or Discharge, dated 05/23/22, revealed Resident #68 was discharged to the hospital on [DATE]. There was no evidence the facility provided the notification to the Office of the State Long-Term Care Ombudsman. Interview on 07/21/22 at 2:30 P.M. [...]

Inspectors wrote2. Review of the medical record for Resident #24 revealed an admission date of [DATE]. His diagnoses included acute kidney failure, insomnia, cerebrovascular disease, depression, and diabetes mellitus two. Review of the MDS assessment for Resident #24, dated [DATE], revealed he was cognitively intact. Further review of the MDS assessment revealed he required assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Resident #24's physician orders revealed an order for Trazodone (antidepressant medication) 100 milligram (mg), take one tablet by mouth everyday at bedtime and Sertraline HCL (antidepressant medication) 25 mg tablet give one and a half tablets daily at bedtime. Review of the Care Plans for Resident #24 revealed he had a care plan in place for depression with an onset date of [DATE]. [...]

Inspectors wrote2. Review of Resident #64's medical record revealed an admission date of 10/19/21. admission diagnoses included chronic respiratory failure, diabetes, heart failure, major depressive disorder, bipolar disorder, and unspecified protein calorie malnutrition. Review of Resident #64's MDS assessment dated [DATE] revealed Resident #64 was cognitively intact. The MDS revealed the resident required dependent two-person assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the medical record for Resident #64 revealed no evidence of a care conference having been held with Resident #64. Interview with Resident #64 on 07/18/22 at 1:44 P.M. revealed he had not been invited to nor had he attended any care conference. Resident #64 denied any staff discussion related to his goals or preferences in regard to his care at the facility. [...]

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to timely identify a pressure ulcer. This affected one (Resident #32) out of two residents reviewed for pressure ulcers. The facility census was 61.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure a resident did not have access to hazardous substances. This affected one (Resident #24) out of one resident reviewed for medication storage. The facility census was 61.

Inspectors wroteBased on medical record review, resident and staff interviews, and policy review, the facility failed to ensure catheter care was completed as ordered. This affected one (Resident #27) out of two residents reviewed for catheter care. The facility census was 61.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure resident meal intakes and weights were routinely monitored. This affected two (Resident #27 and #43) out of two residents reviewed for nutrition. The facility census was 61.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure residents had the appropriate emergency tracheostomy supplies at bedside and had oxygen tubing changed timely. This affected two (Resident #3 and #42) out of three residents reviewed for respiratory care. The facility census was 61.

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to appropriately monitor and assess resident dialysis access sites. This affected two (Resident #15 and #43) out of two residents reviewed for dialysis. The facility census was 61.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to timely implement a pharmacy recommendation which was approved by the physician. This affected one (Resident #64) out of six residents reviewed for unnecessary medications. The facility census was 61.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure a medications were stored appropriately. This affected one (Resident #24) out of one resident reviewed for medication storage. The facility census was 61.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure residents were provided dental services in a timely manner. This affected one (Resident #50) out of one resident reviewed for dental services. The facility census was 61.

Inspectors wroteBased on medical record review and staff interview, the facility failed to accurately document the administration of tube feeding. This affected one (Resident #27) out of one resident reviewed for tube feeding. The facility census was 61.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to practice proper hand hygiene during a wound dressing change. This affected one (Resident #27) out of one resident observed for wound dressing changes.

Inspectors wroteBased on medical record review, observations, staff and resident interviews, policy review and review of medication information from Medscape, the facility failed to ensure a resident's pain was properly managed. This resulted in actual harm when Resident #24 experienced uncontrolled severe pain and had difficulty sleeping. This affected one (#24) of two residents reviewed for Pain Management during the survey. The facility census was 113.

Inspectors wroteBased on observation, medical record review, staff and resident interview, review of facility policy and review of medication information from Medscape, the facility failed to ensure a resident on anti-coagulation therapy received adequate monitoring of blood coagulation time via laboratory testing as ordered by the physician. This resulted in actual harm when Resident #110 experience a critically high blood coagulation time after bi-weekly blood coagulation monitoring tests had not been completed over a two week period and subsequently required administration of Vitamin K to reverse the over-anticoagulation of the resident's blood. This affected one (#110) of five residents reviewed for unnecessary medications. The facility census was 113.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to properly store resident medication. This had the potential to affect 46 resident's (#9, #16, #18, #20, #21, #22, #23, #27, #30, #32, #35, #36, #37, #38, #40, #46, #47, #52, #54, #56, #57, #60, #61, #66, #69, #70, #72, #74, #76, #77, #80, #81, #84, #92, #96, #97, #101, #103, #104, #105, #106, #110, #111, #422, #423, and #424) the facility identified as cognitively impaired and independently mobile and that could access the unsecured medications. The facility census was 113.

Inspectors wroteBased on observation, medical record review, and staff and resident interview, the facility failed to accommodate a residents needs by ensuring the call lights were made readily available to residents who were capable of using them. This affected one (#110) of 32 residents observed for access to call lights. The facility census was 113.

Inspectors wroteBased on medical record review, staff and resident interviews, and review of facility policy, the facility failed to timely respond to resident concerns with missing personal property. This affected two (#24 and #93) of three reviewed for personal property during the investigation stage of the annual survey. The facility census was 113.

Inspectors wroteBased on medical record review and resident and staff interview, the facility failed to provide written notification of transfer when a resident was transferred out of the facility to the hospital. This affected one (#93) out of two residents reviewed for Hospitalizations during the survey. The facility census was 113.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure an Minimum Data Set (MDS) assessments was coded accurately. This affected one (#115) of three residents closed records reviewed for MDS assessment accuracy. The census was 113.

Inspectors wroteBased on observation, medical record review, staff and resident interview and policy review, the facility failed to develop and implement comprehensive plans of care related for contracture care and management. This affected two (#15 and #59) of two reviewed for Positioning/Mobility. The facility census was 113.

Inspectors wroteBased on observation, medical record review, staff and resident interview, and policy review, the facility failed to ensure that each resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming related to nail care. This affected two (#59 and #24) of five residents reviewed for Activities of Daily Living. The facility census was 113.

Inspectors wroteBased on observation, medical record review, and staff and resident interview, the facility failed to ensure that each resident with limited range of motion received appropriate treatment, services, and devices to improve range of motion or prevent further decline. This affected one (#15) of two residents reviewed for Positioning/Mobility. The facility census was 113.

Inspectors wroteBased on observation, medical record review, and staff and resident interview, the facility failed to maintain the resident call system in good working order. This affected one (#37) of 32 residents observed for access to call lights. The facility census was 113.