Inspection·June 18, 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 medical record review, staff and resident interviews, observations, review of a facility Self-Reported Incident (SRI), review of a video, and policy review, the facility failed to maintain an environment free from pests. This affected two (#60 and #19) of the three residents reviewed for the environment. The facility census was 58. Residents Affected - Few Findings include: Review of the medical record for Resident #60 revealed an admission date of 05/20/25 and discharged on 05/27/25. Diagnoses included chronic respiratory failure with hypoxia, tracheostomy (trach), nontraumatic intracerebral hemorrhage, and diabetes mellitus. Review of a physician order for Resident #60 dated 05/22/25, revealed the resident was ordered to have trach checks and observations completed four times per day and as needed. Review of the discharge Minimum Data Set (MDS) assessment for Resident #60 dated 05/27/25, revealed Resident #60 was dependent for all activities of daily living (ADLs). Review of the facility SRI, dated 05/29/25, revealed the facility completed staff and resident interviews and observations. Review of a statement by Certified Nursing Assistant (CNA) #209 stated when she went to help another aide care for Resident #60, there were ants crawling on the resident. Review of the statement by CNA #222 stated on 05/25/25, Resident #60 had ants on her bed and her body. CNA #222 stated Resident #60 was washed up and repositioned. CNA #222 stated a personal blanket was noted on her bed covered with ants which was bagged and set aside for the family to pick up. Further review of staff statements revealed a statement dated 05/28/25 by the Administrator which stated she watched a video provided by Resident #60's husband which showed two to four ants on Residents #60's tracheostomy but none in the throat area. Review of the SRI revealed after observations and staff and resident interviews, the facility did not substantiate the allegation of neglect due to lack of evidence. Interview on 06/17/25 at 9:50 A.M. with Respiratory Nurse #208 revealed on 05/25/25 around 2:00 A.M. she observed about five ants on Resident #60's upper arm and on her bed but not on the resident's trach. Respiratory Nurse #208 stated she immediately notified the nurse and aide who gave Resident #60 a bed bath and changed her linens. Respiratory Nurse #208 stated she did not know where the ants came from and had not seen the ants in Resident #60's room before when providing trach care. Interview on 06/18/25 at 9:03 A.M. with Administrator and Director of Nursing (DON) via phone, revealed the DON stated she was notified by Resident #60's husband that Resident #60 was found to have ants on and around her tracheostomy on the afternoon of 05/25/25. The DON stated she contacted the (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: 366157 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 366157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dunbar Health & Rehab Center 320 Albany Street Dayton, OH 45417 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)