Health inspection·May 1, 2024

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation and interview on 04/23/24 with Licensed Practical Nurse (LPN) #245 confirmed Resident #121's room was messy with numerous large items of trash on the floor under, including several under her bed. LPN revealed these items could been seen from the hallway and confirmed she had not seen housekeeping staff cleaning many resident rooms. Interview on 04/23/24 with Administrator and Environment and Safety Director #260 revealed staff should be keeping resident rooms clean. Both staff acknowledged being unaware of previous concerns brought up during resident council meetings regarding the cleanliness of their rooms. Review of facility policy titled, Resident Council, dated 02/2021 revealed the purpose of resident council was to have a forum to discuss concerns for improvement. The facility department related to a specific issue would be responsible for addressing the listed concern. This deficiency represents non-compliance investigated under Master Complaint Number OH00153356 and Complaint Number OH00152678. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365344 If continuation sheet Page 2 of 4 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 365344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe Rehabilitation and Care Center 957 Becks Knob Road Lancaster, OH 43130 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff and family interviews, the facility failed to ensure resident rooms were maintained in a clean and sanitary manner. This affected three Residents (#92, #94, and #121) of three reviewed for environment. Facility census was 130. Findings include: Observation on 04/22/24 at 11:10 A.M. revealed Resident #92's toilet had brown splattered substance on the toilet riser and toilet bowl. Resident was unable to respond to questions appropriately related to his room cleanliness. Observation on 04/22/24 at 11:38 A.M. revealed Resident #94's had a clear liquid dripped on the floor and a large puddle in front of his recliner. Resident was sitting in his recliner with his feet sitting in the puddle. Resident was unable to respond to questions about the spilled liquid. The splatter and puddle was visible from the hallway. At 11:40 A.M. a nurse walked into the doorway to pass medications and realized it was not the right room and walked away to provide medications to another residents. She did not identify the spill. Observation on 04/22/24 at 11:54 A.M. revealed State Tested Nursing Aide (STNA) #333 was walking with resident in the hall to get to the dining room for lunch. At 12:01 P.M. STNA was observed informing several staff at the nursing station of the spill in residents room. Resident walked through the spill to get out of his room and to the dining area. Observation on 04/22/24 at 12:40 P.M. revealed the spill remained on Resident #94's floor. Interview on 04/22/24 at 3:22 P.M. with STNA #333 confirmed resident had a spill on the floor and she reported she informed staff including housekeeping and the front desk and was told housekeeping staff were on break. She revealed facility had issues with housekeeping and only a few housekeepers clean resident rooms in a thorough manner. She revealed when those staff do not work, resident rooms do not get cleaned. STNA confirmed Resident #92's family typically cleans his room and confirmed family had come in and cleaned the diarrhea splattered on the toilet riser and toilet bowl. Observation on 04/22/24 at 10:45 A.M., 12:55 P. M., 2:00, and 3:50 P.M. revealed Resident #121 had about a dozen pieces of trash on her floor including wrappers for food, wrappers for care products, gloves, tissues etc These items could easily be seen from the hallway. Observation and Interview on 04/23/24 at 8:52 A.M. revealed Resident #121's room had trash on the floor from the previous day and was observed to still be in place. Interview with Resident #121 revealed she was unaware of housekeeping services and stated they had not been in her room. Resident had been admitted for about three weeks at this time. Observation on 04/23/24 from 8:15 A.M. to 10:40 A.M. revealed the housekeeping staff had cleaned only common areas on [NAME] hall. At 10:45 A.M. Housekeeper #255 entered her first Resident room to clean it. Interview on 04/23/24 at 10:55 A.M. with Housekeeper #255 confirmed she was cleaning the first (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365344 If continuation sheet Page 3 of 4 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 365344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe Rehabilitation and Care Center 957 Becks Knob Road Lancaster, OH 43130 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm resident room of the day. She revealed facility should have two to three housekeepers cleaning rooms and one cleaning common areas but they only had one and an additional trainee for the day. She confirmed resident rooms should be cleaned daily and confirmed she only got to a few resident rooms on 04/22/24. When asked about a task list or a check off list, she revealed she had been doing this a long time, and did not carry one. Residents Affected - Few Observation and interview on 04/23/24 with Licensed Practical Nurse (LPN) #245 confirmed Resident #121's room was messy with numerous large items of trash on the floor, including several under her bed. LPN revealed these items could been seen from the hallway and confirmed she had not seen housekeeping staff cleaning many resident rooms. Interview on 04/23/24 with Administrator and Environment Safety Director (ESD) #260 revealed staff should be keeping resident rooms clean. ESD confirmed all resident rooms should be cleaned including bathrooms, and sweeping and mopping floors daily including a recent training to ensure they are getting under the bed. They also revealed resident rooms should have a deep clean at a rate of two rooms per housekeeper per day. Both ESD and Administrator acknowledged being unaware of previous concerns brought up during resident council meetings regarding the cleanliness of their rooms in 01/2024 and 02/2024 but revealed residents had complained 03/2024. Review of Resident council meeting minutes dated 01/18/24 revealed complaints of resident rooms need to be cleaner. No concern forms or facility follow-up was provided upon request. Review of Resident council meeting minutes dated 02/22/24 revealed complaints of resident rooms need to be cleaned better. No concern forms or facility follow-up was provided upon request. Review of Resident council meeting minutes dated 03/21/24 revealed complaints of resident housekeeping to clean under the beds more thoroughly. Facility provided education dated 03/22/24 as their response to the concern related to cleaning under resident beds. Review of the task list titled weekly schedule for infection control housekeepers revealed all rooms are to be cleaned daily, with two rooms getting a complete clean each day. Bathrooms should be cleaned including toilet, sink, and mirror. Mop the floor, dusted and wastebaskets emptied. ESD stated this document was facility policy for housekeeping of resident rooms. This deficiency represents non-compliance investigated under Master Complaint Number OH00153356 and Complaint Number OH00152678. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365344 If continuation sheet Page 4 of 4