Health 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 Page 1 of 2 365187 365187 05/23/2025 Xenia Health and Rehab 126 Wilson Drive Xenia, OH 45385

F 0921 Level of Harm - Minimal harm or potential for actual harm the shower room revealed black substance on the flooring by the walls. The facility confirmed there are 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 This deficiency represents non-compliance investigated under Complaint Number OH00163998. Residents Affected - Some 365187 Page 2 of 2