Inspection·August 29, 2025

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. Based on observations, staff and resident interviews, review of maintenance work order log, and review of the facility work order process form, the facility failed to ensure resident rooms were without holes in the drywall or torn wallpaper. This affected three (#09, #12, and #13) residents out of the four residents reviewed for homelike environment. The facility census was 47.Findings include:1.Review of the medical record for Resident #09 revealed an admission date of 08/03/23 with medical diagnoses of vascular dementia, hypertension (HTN), anxiety, and hypothyroidism. Review quarterly of the Minimum Data Set (MDS) assessment, dated 06/20/25, indicated Resident #09 had severe cognitive impairment and was dependent upon staff for toileting hygiene, transfers, and bathing and was independent with eating. 2. Review of the medical record for Resident #12 revealed an admission date of 09/22/22 with medical diagnoses of congestive heart failure, HTN, diabetes mellitus (DM), and anxiety.Review of a quarterly MDS assessment, dated 06/12/25, indicated Resident #12 was cognitively intact and was dependent upon staff for bathing, toilet hygiene, transfers, and bed mobility.3. Review of the medical record for Resident #13 revealed an admission date of 07/12/22 with medical diagnoses of HTN, DM, hyperlipidemia, and history of cerebral infarction.Review of a quarterly MDS assessment, dated 08/03/25, indicated Resident #13 was cognitively intact and was dependent upon staff for toileting hygiene, required substantial/maximum staff assistance for bathing and bed mobility. The MDS indicated Resident #13 had not transferred during review period. Observation with interview on 08/29/25 at 8:11 A.M. of Resident #13's room revealed two large holes in the wall on the right side of Resident #13's bed. The observation also revealed the wallpaper on the wall on the right side of Resident #13's bed was torn. Interview with Resident #13 confirmed the two large holes in her walls near her bed and stated the holes had been there for a long time.Interview on 08/29/25 at 8:15 A.M. with Licensed Practical Nurse (LPN) #111 confirmed there were two large holes and torn wallpaper on the wall on right side of Resident #13's bed. Observation with interview on 08/29/25 at 9:51 A.M. of Resident #12's room revealed a large hole in the wall behind the bed. The observation also revealed torn wallpaper on the wall behind Resident #12's bed. Interview with Resident #12 confirmed the hole in the wall and the torn wallpaper behind her bed but stated she was not sure how long the wall had been like that. Interview on 08/29/25 at 9:53 A.M. with LPN #111 confirmed Resident #12 had a hole in her wall behind her bed and the wallpaper was torn. Observation with interview on 08/29/25 at 9:58 A.M. with Resident #09's room revealed a hole in the wall behind her bed and torn wallpaper. Interview with Resident #09 stated she was not aware of the hole in the wall or the torn wallpaper.Interview on 08/29/25 at 10:04 A.M. with State Tested Nursing Assistant (STNA) #102 confirmed there was a hole in the wall behind Resident #09's bed and the wallpaper was torn. Review of the facility maintenance log from 06/11/25 to 08/28/25 revealed no documentation to support the facility had identified the holes in the walls in Resident #09's, #12's, and #13's room. Review of the facility work order process instructions, dated 03/06/25, stated staff are to identify maintenance/work (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: 365365 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 365365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Urbana Health & Rehabilitation Center 741 E Water Street Urbana, OH 43078 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)