Health inspection·November 27, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident, family, and staff interviews, policy and procedure review, observations, and record review, the facility failed to provide a safe, clean homelike environment for Resident #12. This affected one (Resident #12) of three residents reviewed for a clean and homelike environment. The facility census was 37. Findings include: Review of Resident #12's medical record revealed an admission date of 10/24/23 with diagnosis including major depressive disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #12 had intact cognition and no rejection of care. Review of Resident # 12's plan of care dated 10/31/23 revealed it was silent for refusal of cleaning services, preferences of not utilizing trash receptacles, or requests of personal item placement for utilization. Observation of Resident #12's room on 11/19/23 at 8:52 A.M. revealed the resident was lying in bed with her eyes closed. The floor under Resident #12's bed and surrounding floor area had a red dried substance, four food wrappers under the bed and surrounding areas, and a towel on the window ledge. There were two bedside tables in her room and one of the table housed a radio, a cup, and a flat screen television lying screen side down, with two dried brown plants with plant type debris surrounding the plants. Interview on 11/20/23 at 3:20 P.M. with the Administrator stated the window air conditioning units in resident rooms had not been winterized or covers placed on them. Subsequent interview on 11/21/23 at 8:30 A.M. with the Administrator stated housekeeping of patient rooms was performed daily along with spot cleaning from floor staff as needed. Observation of Resident #12's room and interview with Resident #12 on 11/21/23 at 3:24 P.M. revealed Resident #12's room continued to not be clean and homelike. The pathway from the door to Resident #12's bed revealed there was a television that was lying screen side down on top of a small ill-fitting stand. On top the television, there were two plants with brown leaves and brown plant debris surrounding the pots. In the corner of the room, there were multiple cobwebs hanging in the corner midway to the ceiling. On the window ledge, there was a white and brown stained towel that stretched across the length of the window ledge and a window unit air conditioner with vents in the open position. Under Resident #12's bed, the red dried substance remained from previous observation (11/19/23 at 8:52 A.M.), multiple food wrappers under her bed and surrounding under the empty bed in the room and food debris throughout the floor of the room. Resident #12 stated she had requested the towel be placed at the window ledge because of the air leaking into the room from the window and the window air conditioner caused her to be cold at times. Resident #12 stated she was told the television was (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 6 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 11/27/2023 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)