Health inspection·May 16, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff, and resident interviews, and review of facility policy, the facility failed to ensure a clean, safe, comfortable environment for all residents. This affected 11 (#02, #06, #19, #31, #32, #35, #38, #44, #53, #70, and #71) residents who resided in the facility. The facility census was 77. Findings include: Review of the medical record for Resident #53 revealed the resident was admitted on [DATE]. Diagnoses included hypoxemia, amyotrophic lateral sclerosis (ALS), gastro-esophageal reflux disease (GERD), essential primary hypertension, obstructive sleep apnea (OSA), and diabetes mellitus (DM). Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #53 was cognitively intact. Resident #53 was dependent on staff for Activities of Daily Living (ADLs). Observation of the facility on 05/13/25 at 11: 30 A.M. with the Director of Housekeeping and Laundry #134 revealed the following findings: a) Resident #02's bathroom was heavily soiled with dirt, debris and an unknown black substance in the corners, the floor was extremely sticky and the cover over the toilet tank was too large and did not properly fit. b) Resident #06's bathroom floor was very sticky, heavily soiled and had black stains throughout the floor. c) The wall behind Resident #19's bed was shredded and torn, the floor around her toilet had an unknown black substance, the cove base below the sink was loose and separated from the wall and there were numerous ceramic tiles missing. d) The wall behind Resident #31's bed was damaged and had exposed drywall, the heater wall was chipped and contained rusted areas, the floor around the toilet was heavily soiled, and the assist bars around the toilet were not secured. e) The wall behind Resident #32's bed was damaged and had exposed drywall, the cove base was separated from the wall under the bathroom sink, and the floor in bathroom was soiled and sticky. f) Resident #35's bed had a heavily soiled sheet with food and debris all over it, the floor had (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 05/16/2025 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)