Health inspection·August 3, 2023

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 staff interview, document review, and observation the facility failed to have a safe homelike environment when they failed to have properly functioning hot water in the back part of the building. This affected 18 residents living in rooms 27-46 (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18). The facility census was 42. Findings include: Observation on 08/02/23 at 11:05 A.M. revealed there was no hot water in the resident shower room on the back hall. Interview on 08/02/23 at 11:07 A.M. with State Tested Nurse Aide (STNA) #10 verified there was no hot water on the back hall in the resident rooms or in the shower room. STNA #10 stated the water has been out for a month. Interview with a confidential resident on 08/02/23 at 11:10 A.M. revealed the resident stated they did not want their name used but there is no hot water in part of the building. Interview with a confidential resident on 08/02/23 at 1:15 P.M. revealed the resident did not want her name used, but they do not have hot water in their room. Interview on 08/02/23 at 2:15 P.M. with Regional Maintenance Director (RMD) #15 verified the hot water was not functioning properly in the back hall. RMD #15 stated there was a leak and after about 20 minutes of running hot water it is back to cold. The hot water tank is 120 gallons tank and after 20 minutes of giving a shower, it is out of hot water and then it takes probably takes 90 minutes for it to fill back up. So we shut the hot water valve back off. The floor is concrete and the pipes are under the floor and we have dug up two places and can not find the leak. We have someone coming out on 08/03/23 to fix a leaky water valve then we have another company who is going to come put compressed air through the pipes so they can find the location of the leak. Review of maintenance documents on 08/03/23 revealed there was invoices for plumbing work on 06/02/23, 06/29/23, 07/05/23, and 07/20/23 where work was done on the water lines including leak detection. 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: 365187 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 365187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Xenia Health and Rehab 126 Wilson 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)