Inspection·November 3, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 observation, staff interview, and facility policy review, the facility failed to maintain safe clean environment. This had the potential to affect all 30 residents. The facility census was 30.Findings Included: Observation on 10/30/25 at 2:23 P.M. in [NAME] hallway there was staining on the ceiling tile around the water sprinkler which was located close to the nurse's station.Interview on 10/30/25 at 2:23 P.M. with Certified Nurse Assistant (CNA) #135 verified there was staining on the ceiling around the water sprinkler down [NAME] hallway.Observation on 10/30/25 at 2:27 P.M. in Summer hallway the air vents in the ceiling were observed, the second and third air vents from the entrance to the hallway had dust, dirt and debris in them, the sixth air vent was observed with staining on the ceiling around the air vent which had visible dust and debris hanging in the air vent.Interview on 10/30/25 at 2:27 P.M. with Physical Therapy Assistant #192 verified the condition of the air vents in Summer hallway as described above.Observation on 10/30/25 at 2:35 P.M. in dining room revealed the ceiling tile near the ice machine was bulging and had an active area that was wet and dripping. The ceiling next to the bulging ceiling tile was observed with multiple areas of staining.Interview on 10/30/25 at 2:35 P.M. with Dietary Aid #171 verified near the ice machine there was a bulging ceiling tile with wet spot dripping down in dining room stating the ceiling tile next to it also had large area of water damage.Observation on 10/30/25 at 2:45 P.M. in the kitchen there was observed an area of approximately 24 inches in diameter where the ceiling had visible damage and the bottom layer of the ceiling surface was pulling away from the ceiling board, this area had an active leak dripping water on the stain-steel kitchen sink located by the kitchen door. Under the sink the wall board was observed to be damaged with open areas around the sink pipe.Interview on 10/30/25 at 2:48 P.M. with [NAME] #165 verified there was an active leak in the kitchen above the main stainless-steel sink. The [NAME] #165 also verified the wallboard under the sink was damaged with open areas around the sink pipe.Observation on 10/30/25 at 2:57 P.M. in Spring hallway the third air vent from the entrance of the hallway near the nurses' station was noted to have staining on the ceiling around the air vent and the vent was visibly soiled.Interview on 10/30/25 at 2:57 P.M. with Licensed Practical Nurse (LPN) #148 verified the condition of the ceiling and air vent on Spring hallway stating there was water damage on the ceiling tile around the dirty air vent near the nurses' station.Interview on 10/30/25 at 3:15 P.M. with Administrator revealed he had been at the facility for a couple months and since he started at the facility there had been leaks in the ceiling in the dining room and the kitchen. The Administrator went on to say there was a leak in his office that was currently dripping in a trashcan.Observation and Interview on 10/30/25 at 4:20 P.M. in Winter hallway with CNA #174 the ceiling above the shower room had staining and the air vent near the shower room was observed with damaged, dirt and debris visible. There was additionally a ceiling tile in the hallway outside resident room [ROOM NUMBER] that was bulging and had staining on the tile. The ceiling tile at the end of (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: 365368 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 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)