Inspection·May 23, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on medical record review, observations, and staff interviews, the facility failed to ensure a resident room was free from holes in wall, free from broken drywall, and free from black debris on the wall. This affected one (#16) out of the three residents reviewed for cleanliness of rooms. Additionally, the facility also failed to ensure the shower rooms were free from black substance along the flooring near the walls. This had the potential to affect 19 (#17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, and #35) residents who use the shower room on the Emerald and [NAME] Halls. The facility census was 35. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 12/12/23 with medical diagnoses of diabetes mellitus, chronic obstructive pulmonary disease, Intellectual Disabilities, and hypertension. Review of the medical record for Resident #16 revealed a quarterly Minimum Data Set (MDS) assessment, dated 03/14/25, which indicated Resident #16 had severely impaired cognition and required set-up assistance for eating and was dependent upon staff for bed mobility, toileting, and bathing. Observation on 05/23/25 at 8:35 A.M. of Resident #16's room revealed a large (around 12 inch) circular hole in the wall behind Resident #16's bedside dresser. The observation revealed the drywall behind the bedside dresser was broken and crumbling and an electrical outlet was located next to the hole in the wall. The observation also revealed broken drywall behind Resident #16's bed with several large cracks noted to the drywall and black debris noted to be scattered on the wall underneath the window. Interviews on 05/23/25 at 8:37 A.M. with Certified Nursing Assistant (CNA) #100 and Licensed Practical Nurse (LPN) #101 confirmed Resident #16's room had a large hole in the drywall near an electrical outlet behind the bedside dresser, broken drywall behind Resident #16's bed, and black debris noted to be scattered on Resident #16's wall underneath her window. Interview with CNA #100 stated the hole in Resident #16's wall had been there for quite some time. 2. Observation with interview on 05/23/25 at 9:03 A.M. with CNA #102 of the Emerald Hall shower room revealed black substance scattered on the flooring by the walls. CNA #102 confirmed the shower room revealed black substance on the flooring by the walls. Observation with interview on 05/23/25 at 10:40 A.M. with Housekeeper #115 of the [NAME] Hall shower room revealed a black substance scattered on the flooring by the walls. Housekeeper #115 confirmed (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 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 05/23/2025 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)