Inspection·February 27, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Legionella Water Management Plan, review of Water Management Evaluation Tool, interviews, and policy review, the facility failed to follow public health authority recommendations to revise the Water Management Plan in a timely manner and failed to monitor pH levels of water sources. This had the potential to affect all residents. The facility census was 40: Residents Affected - Many Findings include: Review of Legionella Water Management Plan dated [DATE] revealed the facility identified members of the Water Management Team with the exception of naming the Maintenance Director; described the buildings water systems including circulation of water, number of mixing valves and hot water tanks, absence of holding tanks, points of recirculation, and location of tees; and listed the verification process including weekly checks and documentation of pH levels and water temperatures and flushing unused sinks and showers. There were no parameters listed for how long unused sinks and showers were flushed and no parameters for pH and temperature levels. Review of Water Management Evaluation Tool dated [DATE] revealed Bureau of Infections Disease (BID) Specialist #50 assessed the facility's Water Management Program (WMP) and provided 37 comments with recommendations for improvements: • It was unclear whether the facility had recirculation loops or circulatory pumps. • It was unclear what types of water system components/devices were present (shower wands, hoses, bathtubs, drinking fountains). • The WMP did not identify which team members were responsible for implementing the WMP and direct corrective action as needed; maintaining working knowledge of the facility water system(s); identifying system control locations and control limits; and monitoring and documenting program performance. • The WMP did not provide any information regarding description of the type of piping material, age, (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 3 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 02/27/2025 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)