Inspection·March 4, 2025

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff and resident interviews, interview with the Pest Control Representative, review of pest control notes, and review of facility policy, the facility failed to maintain the kitchen and dining room area free from pests. This had potential to affect all 74 facility residents. Residents Affected - Many Findings include: Review of pest control notes dated 09/30/24, 10/22/24, 11/27/24, 01/03/25 and 01/27/25 revealed the facility had treatments completed for roaches and mice traps were monitored. Observation and interview on 03/04/25 from 9:40 A.M. to 10:05 A.M. with Kitchen Manager (KM) #205 revealed facility had mice a few weeks ago but they had been treated. Observation of the food area found an extremely large amount of brownish black pellets. KM #205 verified these to be mouse excrement. These were found on baking sheets; in the roboku; in boxes of paper products; in boxes and containers of food such as chips, gelatin, condiments, and packaging with pop cans; on cookie sheets with food on it; and on the silverware holder. KM #205 could not confirm if the mouse droppings were new or old. Two large trashcans were also found to be uncovered. Two smaller trashcans had trash in them with no trash bag and were uncovered. KM confirmed the trash cans had no lids and he was unsure if the facility had lids for any trashcans. Observation and interview on 03/04/25 at 10:06 A.M. with Dietary Aide (DA) #210 confirmed both living and dead roaches were observed in the dining room in the last week. DA #210 confirmed roaches were found mainly along the side of the room closest to the staff hallway and the doors to the hallway. The area was observed to have a thick black line on the floor of dirt and debris including crumbs along the wall with a crevice that held the debris. Interview on 03/04/25 at 12:45 P.M. with the Pest Control Representative revealed the facility had been getting services for pest control. She reported the pest control agent would give recommendations to the facility on how to help rid pests in between visits. These recommendations could include cleaning, dealing with trash, and getting rid of pest debris such as excrement and dead insects to see new movement vs old movement. She also reported the facility was not paid up to date for services from 11/2024 through 02/2024. Interview and observation on 03/04/25 at 1:46 P.M. with Maintenance Director (MD) #225 and the Administrator confirmed observation of a black line along the dining room wall. MD #225 confirmed they had replaced base boards but the new ones did not fit the same way and facility needed a piece of quarter round to cover the crevice. They confirmed dirt and debris, including food crumbs, get swept and pushed into the crevice which would be enticing for insects, mice, or other pests. MD #225 confirmed the pest control company had provided directions for prep prior to their arrival for spaces they intend to treat, but also had given some basic instructions on cleanliness and keeping areas free of food and debris to help prevent ongoing issues. MD #225 confirmed he had not been checking on how staff follow those recommendations. Review of facility policy titled Sanitation, dated 11/2022, revealed food service areas shall be maintained in a clean and sanitary manner, kept free and clear of garbage and debris and protected from rodents and insects. Kitchen waste shall be stored in clean leakproof tightly closed containers and disposed of daily and garbage containers shall be affixed with lids or otherwise covered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 2 of 3 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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 0925 This deficiency represents non-compliance investigated under Master Complaint Number OH00162699, OH00162474 and OH00161757. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 3 of 3