Health inspection·April 26, 2024

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 observation, resident interview, and staff interview, the facility failed to ensure exterior windows in resident rooms were maintained. This affected seven (Residents #03, #09, #11, #25, #26, #30, and #31) of 37 residents residing at the facility. Findings include: Observation of the facility on 04/26/24 at 11:21 A.M. revealed there was plastic covering Resident #09 and Resident #11's windows and blinds, and the blinds could not be opened without poking a hole in the plastic. Further observation of the facility revealed there were no screens in the exterior windows in Resident #03, #25, #26, #30, and #31's rooms. Interview with Maintenance Director #80 on 04/26/24 at 11:21 A.M. verified there was plastic covering Resident #09 and Resident #11's windows and blinds, and the blinds could not be opened without poking a hole in the plastic. Maintenance Director #80 stated Resident #09 and Resident #11 had plastic over their exterior windows and blinds because the windows were old and allowed cold air in Resident #09 and Resident #11's rooms. Maintenance Director #80 stated the plastic was placed on the windows to keep the cold air from coming in the room. Maintenance Director #80 also confirmed there were no screens in the exterior windows in Resident #03, #25, #26, #30, and #31's rooms and that all windows were made with screens. Maintenance Director #80 stated some of the windows had been missing screens for a long time. Interview on 04/26/24 at 11:28 A.M. with Resident #25 revealed she was not able to open her window because there was not a screen in her window. Resident #25 stated that a squirrel came in her room one time when she had her window open because there was no screen in the window. Interview with Resident #09 on 04/26/24 at 11:35 A.M. revealed he had plastic over his window in his room because his room got cold. Resident #09 stated his room had been warmer since the plastic was applied over the window. Interview with Resident #11 on 04/26/24 at 11:42 A.M. revealed he had plastic over his window in his room because he had big temperature fluctuations in his room. Resident #11 stated the plastic has helped with the fluctuations. Resident #11 stated he thought the fluctuations were due to the windows being old. Interview with Resident #03 on 04/26/24 at 11:54 A.M. revealed he did not think he had a screen in his exterior window in his room. Resident #03 stated he enjoyed opening the window in his room and did not have any issues with bugs entering his room. (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: 365626 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 365626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellbrook Health and Rehab 1957 North Lakeman Drive Bellbrook, OH 45305 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)