Inspection·April 2, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Observation of the facility during the initial tour on 04/02/24 at 8:10 A.M. revealed the wood-looking floor tiles were missing in an area approximately three feet by five feet and near the entrance to Unit-A nurses' station. The area where the missing floor tiles were located had exposed concrete extending past the door frame to the wall. There was standing water on the floor near the main entrance doors and wet bath blankets soaking up the water. Residents Affected - Some Interview with Physical Therapy Assistant (PTA) #213 on 04/02/24 at 8:11 A.M. confirmed the large area of the missing floor tiles and the exposed concrete. PTA #213 confirmed the standing water and the large amount of soaked bath blankets lying in the floor with water all around them. PTA #213 stated the water was coming from exterior door where the staff clocked in. Observation of Resident #28 and #69s' room on 04/02/24 at 8:14 A.M. with State Tested Nursing Assistant (STNA) #175 revealed a strong smell of urine in the resident's bathroom, a black unknown substance along the walls and on the floor around the toilet, peeling paint hanging from the bathroom wall tiles and cobwebs throughout the corners of their bathroom. Observation also revealed a rolled-up bath towel stuffed around the window and on the windowsill. Resident #28 stated she rolled up the towel up to help eliminate the cold draft where the window was not sealed. Resident #28 stated her roommate's electric bed did not work and their shared bathroom always had a strong smell of urine that did not go away. Resident #69 was observed to be lying in a bed and the bed was in a low and flat position. Resident #69 stated her bed was not working. Observation at the same revealed STNA #175 was trying to move Resident #69's bed position using the remote attached to the bed and the bed would not move. Interview with STNA #175 at the same time verified the condition of Resident #28 and #69's room and verified Resident #69's bed was not working properly. Observation of Resident #32's room on 04/02/24 at 8:47 A.M. with STNA #219 revealed numerous rips in the wallpaper behind the resident's bed, crumbling plaster throughout the ripped wallpaper and a black unknown fuzzy substance in the plaster and behind the wallpaper that was pulled away from the walls. There was an unknown black fuzzy substance on the wall under the sink and around the toilet, unknown type of brown debris around the toilet and along the bathroom wall. Interview with STNA #219 at the same time, verified the condition of Resident #32's room. Observation of an area across from Unit-A nurse's station on 04/02/24 at 8:53 A.M. with Housekeeper Laundry Supervisor (HLS) #151 revealed there was a corner of the wall where the plaster was crumbling with metal exposed. Interview with HLS#151 at the same time confirmed the corner wall had crumbling plaster with metal exposed. Observation of the 200-hall resident shower room on 04/02/24 at 8:55 A.M. with HLS #151 revealed the shower room had a strong unknown odor, a blackish color throughout the floor near the sink and the toilet and a black fuzzy substance along the walls Interview with HLS#151 at the same time verified the condition of the 200-hall shower room. HLS#151 stated the smell was coming from the trash can under the sink which contained an unbagged, soiled incontinence briefs with feces in it. Observation of Resident #33, #35 and #36s' room on 04/02/24 at 8:56 A.M. with HLS #151 revealed the following concerns: an electric outlet was hanging out the wall, there were numerous holes in the walls, a large area of the wall had been painted white over the wall paper with large brown stains coming through the white painted area, the wallpaper was ripped in areas with crumbling plaster around the rips and in other areas, the wallpaper was peeled away from the walls with a black fuzzy substance on the walls and behind the rips and peeling wallpaper, the resident's bathroom had peeling paint hanging from the wall tiles. Interview with HLS #151 at the same time verified the condition of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 2 of 3 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 365022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atrium Nursing and Rehabilitation 1301 North Monroe Drive Xenia, OH 45385 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)

F 0584 the resident's room. Level of Harm - Minimal harm or potential for actual harm Observation of Resident #17's room [ROOM NUMBER]/02/24 at 8:58 A.M. with HLS #151 revealed the following concerns: Numerous rips in the wallpaper, broken crumbling plaster, an unknown black fuzzy substance on the wall, black stains on the bathroom wall and floor, numerous dead bugs in the bathroom light fixture, and gnats were flying around the bathroom. Interview with HLS #151 at the same time verified the condition of Resident #17's room. Residents Affected - Some Observation of Resident #02 and #03s' room on 04/02/24 at 9:00 A.M. with STNA #178 revealed the room was designed to house three residents. The area where the third resident would be housed had two empty beds pushed together and various items that were being stored on the two empty beds. The room was cluttered, and debris was scattered across the floor. There was torn wallpaper with crumbling plaster around the tears and an unknown black fuzzy substance on the walls around the torn wallpaper. Interview with STNA #178 at the same time confirmed the condition of the residents' room. STNA #178 stated the two beds being stored were broken and she did not know why the residents' room was being used for storage. Observation of Resident #05, #06, and #07s' room on 04/02/24 at 9:02 A.M. with Registered Nurse (RN) #164 revealed a large swarm of gnats crawling all over Resident #06's bed and gnats were flying all around the room. The residents' toilet had a large black ring around the inside of the toilet bowl, the bathroom had numerous black stains along the wall and on the floor under and around the toilet. The residents' room was cluttered with debris on the floor and a sock was rolled up and stuffed underneath one leg of Resident #06's bed. Interview with RN #164 at the same time verified the condition of the residents' room. Observation of the Unit-B dining room on 04/02/24 at 9:14 A.M. with Licensed Practical Nurse (LPN) #167 revealed on the patio directly outside the sliding glass doors there was a large pile of trash which included refuse, pieces of wood, and pieces of siding. The ceiling tiles had large brown stains directly over the residents' dining tables. Interview with LPN #167 at the same time confirmed the large pile of trash on the patio outside the patio doors and the large brown stains on the white ceiling tiles over the dining room tables. Review of the facility policy titled, Resident Rights, undated, stated it was the duty of all members of the nursing staff to ensure every resident under their care is accorded all rights. This deficiency represents noncompliance investigated under Complaint Number OH00152368. This deficiency is an example of continued noncompliance from the surveys dated 03/04/24 and 03/14/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 3 of 3