Inspection·September 19, 2025

F 0921 Level of Harm - Potential for minimal 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. Based on observations, record review, and resident and staff interview, the facility failed to ensure a clean and sanitary environment. This had the potential to affect all 92 residents residing in the facility. Findings include:Review of quote summary for facility hallways dated 09/18/25 with an expiration date upon 30 days notice, revealed there was an estimate to replace the flooring throughout the facility. The facility was unable to provide any other quote summaries for replacement of the flooring. Observation on 09/19/25 at 10:21 A.M. revealed widespread soiling, staining and wear throughout the facility's carpeted areas. Carpet tiles, each measuring 20 in length by (x) 20 inches in width, were found in poor condition with extensive dark brown discoloration, water damage, bright yellow blotches and sticky adhesive residue. The overall appearance of carpet was grimy and heavily trafficked, with visible signs of neglect, staining and deterioration. Observation on 09/19/25 at 10:24 A.M. revealed hallway 200-218 (431 Hall), approximately measuring 81 tiles in length by five in width, totaling around 405 tiles. Of these, 52 tiles were visibly soiled. Stains varied in size from small two x two-inch spots to full-tile coverage. The carpet displayed irregularities such as hardened adhesive buildup, deep-set wear patterns and fiber pilling. Many stains appeared dark, crusted and dried into the fibers, with a heavy concentration in the first part of the hallway, giving the impression of long-term accumulation. Interview on 09/19/25 at 10:24 A.M. revealed Housekeeping Staff Member (HSM) #386, who stated she worked at the facility for years, confirmed the carpets were extremely stained throughout and have been in this condition for some time. Interview on 09/19/25 at 10:26 A.M. revealed Registered Nurse #174 stated the carpets have always been dirty and worn. She noted that the flooring was consistently soiled throughout the hallways in the entire facility and mentioned hearing from management that floor replacement was being considered. Observation on 09/19/25 at 10:30 A.M. revealed hallway 219-232 (437 Hall), measuring 64 tiles in length by five in width, totaling 320 tiles. A total of 37 tiles were soiled. Cart track marks and shadowing formed visible linear patterns, with six tiles on the left, three on the right and another three on the left again. The largest stain, located about a quarter of the way down the hallway, affected four corner tiles and appeared dark, greasy and oil-like, covering roughly 25% of each tile. Smaller stains were scattered and sticky, resembling dried glue or adhesive. The carpet showed signs of wear, fiber breakdown and embedded grime. Interview on 09/19/25 at 10:31 A.M. revealed HSM #142 reported that due to reduced staffing hours, carpets were no longer cleaned regularly. HSM #142 described the flooring as being covered in random stains and admitted that despite efforts to maintain cleanliness, the condition has worsened over time. Observation on 09/19/25 at 10:34 A.M. revealed hallway 233-241, measuring 44 tiles in length by five in width, totaling approximately 220 tiles. Nine tiles were soiled, primarily with small splatter-like stains scattered across the surface. The carpet showed signs of adhesive residue, wear staining and fiber pilling, giving the area a patchy and unkempt appearance. Observation on 09/19/25 at 10:40 A.M. revealed hallway 325 near the elevator had a large, (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: 366100 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 366100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Post Acute 1001 Alex Bell Road Centerville, 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)