Health inspection·April 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure the facility was free from pests. This had potential to affect all 81 facility residents. The census was 81. Residents Affected - Many Findings include: 1. Review of Resident #11's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including multiple fractures of the ribs right side, pain in unspecified joint, congestive heart failure, chronic obstructive pulmonary disease unspecified, legal blindness, urinary tract infection, angina pectoris and heartburn. Review of Resident #11's admission assessment dated [DATE] revealed the resident was oriented to person, place, time, and situation. Interview with Resident #11 on 04/04/25 at 8:14 A.M. revealed the resident saw a large cockroach in her bathroom a few days ago that was over one inch long. 2. Review of Resident #19's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus with diabetic polyneuropathy, chronic obstructive pulmonary disease, mood disorder due to known physiological condition, arthropathy and unspecified convulsions. Review of Resident #19's admission assessment dated [DATE] revealed Resident #19 was alert and oriented to person, place, and situation. Interview with Resident #19 on 04/04/25 at 8:19 A.M. revealed the resident saw a cockroach in his room near his doorway a few days ago. 3. Review of Resident #24's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including congestive heart failure, type two diabetes mellitus without complications, bipolar disorder, anxiety disorder, muscle weakness, hyperlipidemia and hypertension. Review of Resident #24's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Interview with Resident #24 on 04/04/25 at 8:20 A.M. revealed the resident saw multiple cockroaches since residing at the facility. (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: 365764 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 04/04/2025 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)