Xenia Health and Rehab

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure medications were administered as ordered resulting in two medication errors of 33 medication opportunities which resulted in a 6.06 percent (%) error rate. This affected one (Resident #15) of three residents reviewed for medication administration. The facility census was 27 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) received 90-day and annual performance evaluations and CNAs received at least twelve hours of in-services annually. This affected three (CNA #32, CNA #36 and CNA #45) of the three CNAs reviewed for performance evaluations and annual in-services. The facility census was 34.1) Review of CNA #32's personnel file revealed CNA #32 was hired at the facility on 05/22/24. Further review of CNA #32's personnel file revealed CNA #32 did not have an annual performance evaluation from 05/22/24 to 07/30/25 and CNA #32 did not have any documented in-service education from 05/22/24 to 07/30/25. Interview with Regional Support #804 on 07/31/25 at 7:31 A.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food temperatures were maintained in a manner to prevent foodborne illness. This affected all 34 residents residing in the facility as the facility indicated all residents receive food from the kitchen. The facility census was 34. Observation of the facility's kitchen on 07/29/25 at 7:30 A.M. revealed [NAME] #43 was serving food from the stove and placing the made plates on the food cart that was not insulated. [NAME] #43 took the temperature of the food items on the stove and again while on the food cart. The gravy was 128.3 degrees Fahrenheit, the boiled eggs were 73.4 degrees Fahrenheit, and the scrambled eggs were 87 degrees Fahrenheit. The gravy, boiled eggs and scrambled eggs were located on the stove. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medical Director or his or her designee attended quarterly Quality Assessment and Assurance (QAA) committee meetings. This affected 34 out of 34 residents residing in the facility. The facility census was 34. Review of the facility's QAA meeting sign in sheets from 09/18/24 to 02/18/25 revealed the Medical Director or their designee did not attend the QAA meetings held from 09/19/24 to 02/17/25. Interview with the Administrator on 07/31/25 at 1:38 P.M. verified the Medical Director or their designee did not attend the QAA meetings held from 09/19/24 to 02/17/25.

Inspectors wroteBased on interview and record review, the facility failed to implement their tuberculosis control plan for tuberculosis testing of newly hired employees. This affected four (The Administrator, Licensed Practical Nurse (LPN) #30, Certified Nursing Assistant (CNA) #36 and CNA #41) out of eight newly hired employees reviewed for tuberculosis testing. This also affected 34 out of 34 residents residing in the facility. The facility census was 34. 1) Review of the Administrator's personnel file revealed the Administrator was hired at the facility on 03/06/25. Further review of the Administrator's personnel file revealed the Administrator did not have a tuberculin skin test or other test to rule out TB completed upon hire. Interview with Regional Support #804 on 07/31/25 at 7:31 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident Funds Authorizations were signed and witnessed for residents that had deposited funds in resident funds accounts at the facility. This affected three (#03, #10 and #34) out of the five residents reviewed for resident funds accounts. The facility census was 34. 1) Review of the medical record for Resident #34 revealed an admission date of 10/19/19. Diagnoses included chronic obstructive pulmonary disease (COPD), dementia, and type II diabetes mellitus (DM II). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14. Review of the facility's Resident Funds Accounts Balance Sheet dated 07/30/25 revealed Resident #34 had $1552.74 dollars in her resident funds account. [...]

Inspectors wroteBased on staff interview and record review, the facility failed to ensure a resident on Medicaid was notified when their account reached $200.00 dollars less than that supplemental security income (SSI) resource limit for one person and the facility failed to ensure a resident's personal funds held in a resident's funds account were conveyed within 30 days of discharge. This affected two (#31 and #48) out of the five residents reviewed for resident funds accounts. The facility census was 34. 1)Review of the medical record for Resident #31 revealed an admission date of 07/30/24. Diagnoses included cerebral infarction, hepatitis B, type II diabetes mellitus (DM II), and depression. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's code status matched in the separate paper chart and a resident's Do Not Resuscitate (DNR) order form was signed by the physician in the paper chart. This affected one (#03) of the 16 residents reviewed for code status. The facility census was 34. Review of Resident #03's chart revealed Resident #03 was admitted to the facility on [DATE] with sepsis, type two diabetes mellitus with diabetic neuropathy, heart failure, type two diabetes mellitus with hypoglycemia without coma, sleep apnea, muscle weakness and progressive supranuclear ophthalmoplegia. Review of Resident #03's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #03's paper chart revealed Resident #03 did not have a DNR order form signed by a physician in the paper chart. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received beneficiary notices to inform them of the right to an expedited review or about the potential non-coverage and the option to continue services with the beneficiary accepting financial liability for the services. This affected two (#46 and #47) of the three residents reviewed for beneficiary notices. The facility census was 34. 1) Review of Resident #46's chart revealed Resident #46 was admitted to the facility on [DATE] with cellulitis, other asthma, acute embolism and thrombosis of right femoral vein, rheumatoid arthritis, unspecified macular degeneration, Parkinson's disease with dyskinesia, and other intervertebral disc displacement lumbar region. Review of Resident #46's census information from 02/26/25 to 04/03/25 revealed Resident #46's payer source was Medicare Part-A from 02/26/25 to 04/03/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received bed hold notices for transfers to the hospital. The facility also failed to notify the Ombudsman of a resident's transfer to the hospital. This affected one (#03) of the one resident reviewed for hospitalization. The facility census was 34. Review of Resident #03's chart revealed Resident #03 was admitted to the facility on [DATE] with sepsis, type two diabetes mellitus with diabetic neuropathy, heart failure, type two diabetes mellitus with hypoglycemia without coma, sleep apnea, muscle weakness and progressive supranuclear ophthalmoplegia. Review of Resident #03's chart from 02/02/24 to 07/30/25 revealed there was no documentation that Resident #03 received a bed hold notice for her 03/25/25 and 05/17/25 discharges to the hospital. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a significant change Minimum Data Set (MDSs) assessment was completed for a resident that admitted to hospice. This affected one (#43) of 15 residents reviewed for MDS accuracy. The facility census was 34. Review of Resident #43's chart revealed Resident #43 was admitted to the facility on [DATE] with malignant neoplasm of bladder, unspecified protein calorie malnutrition, chronic obstructive pulmonary disease, anemia, atrial fibrillation, hyperlipidemia, history of falling, muscle weakness, hypokalemia, retention of urine, hydroureter and sepsis. Resident #43 was discharged from the facility on 07/05/25. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a significant change in status Pre-admission Screening and Resident Review (PASARR) was completed for a resident with a new mental health diagnosis. This affected one (#23) of the two residents reviewed for PASARRs. The facility census was 34. Review of Resident #23's medical record revealed that he was admitted to the facility on [DATE] with diagnoses that included cerebral vascular accident, dysphagia, diabetes mellitus type 2, blindness in the right eye, congestive heart failure, bipolar disorder, anxiety, depression, malnutrition and dementia. Review of Resident #23's facility assessments from March 2025 to July 2025 revealed Resident #23 did not have a significant change PASARR completed for diagnosis of bipolar disorder. [...]

Inspectors wroteBased on review of the medical record, interviews, observations, and policy review, the facility failed to ensure residents, who were unable to carry out activities of daily living (ADLs) were provided grooming for facial hair. This affected one (#38) resident of three reviewed for ADLs. The facility census was 34. Review of the medical record for Resident #38 revealed an admission date of 01/02/25. Diagnoses included type II diabetes mellitus (DM II), altered mental status, and schizophrenia. Review of the care plan dated 01/08/25 revealed Resident #38 had an ADL self-care performance deficit related to weakness, history of being a victim of physical abuse by a family member, and trauma. [...]

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure medications were within expiration date in the medication cart. This had the potential to affect three (#02, #06, and #15) of the three residents who were administered Pro-Stat. The facility census was 34. Observation on [DATE] at 3:11 P.M. with Licensed Practical Nurse (LPN) #803, revealed the [NAME] Hall medication cart had a Pro-Stat (albuterol) inhaler opened and was expired. The manufacturer's expiration date was marked as [DATE]. Interview with LPN #803 at the same time, verified the Pro-Stat inhaler had expired and needed to be discarded. Observation on [DATE] at 3:23 P.M. with LPN #30, revealed the Emerald Hall medication cart had a Pro-Stat inhaler that was opened and expired. The manufacturer's expiration date was marked as [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a cognitively impaired resident was explained or understood an Arbitration Agreement prior to signing the agreement. This affected one (#38) of the three residents reviewed for arbitration agreements. The facility census was 34. Review of Resident #38's chart revealed Resident #38 was admitted to the facility on [DATE] with adult physical abuse confirmed subsequent encounter, rectal prolapse, hypertension, schizophrenia, and altered mental status. Review of Resident #38's Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #38 had a BIMS score of a one indicating Resident #38 was severely cognitively impaired. Review of Resident #38's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. [...]

Inspectors wroteBased on medical record review, observations, and staff interviews, the facility failed to ensure a resident room was free from holes in wall, free from broken drywall, and free from black debris on the wall. This affected one (#16) out of the three residents reviewed for cleanliness of rooms. Additionally, the facility also failed to ensure the shower rooms were free from black substance along the flooring near the walls. This had the potential to affect 19 (#17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, and #35) residents who use the shower room on the Emerald and [NAME] Halls. The facility census was 35.

Inspectors wroteBased on review of Legionella Water Management Plan, review of Water Management Evaluation Tool, interviews, and policy review, the facility failed to follow public health authority recommendations to revise the Water Management Plan in a timely manner and failed to monitor pH levels of water sources. This had the potential to affect all residents. The facility census was 40:

Inspectors wroteBased on record review, interview, and review of policy, the facility failed to assess residents identified prior to admission as a fall risk and failed to thoroughly investigate a fall. This affected two (Residents #38 and #43) of three residents reviewed for falls. The facility census was 42.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, staff interview, review of the fall investigation, review of witness statements, and review of the hospital records, the facility failed to ensure residents were safely transferred in a manner to prevent an avoidable major injury as care planned and per facility policy. This resulted in Actual Harm on 02/27/24 when State Tested Nurse Aide (STNA) #500 transferred Resident #28 from the bed to the wheelchair without assistance as required by Resident #28's plan of care resulting in Resident #28 sliding down in the front of the wheelchair and her left shoulder making contact with the wheelchair. Subsequently, Resident #28 was sent to the local hospital where she was diagnosed with a closed fracture of the left shoulder. [...]

Inspectors wroteBased on observations, staff interview, and facility policy review, the facility failed to properly store food in the dry storage area. This had the potential to affect all 37 residents who received food from the kitchen. The facility census was 37.

Inspectors wroteBased on resident, family, and staff interviews, policy and procedure review, observations, and record review, the facility failed to provide a safe, clean homelike environment for Resident #12. This affected one (Resident #12) of three residents reviewed for a clean and homelike environment. The facility census was 37.

Inspectors wroteBased on record review, facility policy review, and staff interview, the facility failed to administer a resident's wound treatments per physician orders. This affected one (Resident #3) of three residents reviewed for wounds. The facility census was 37.

Inspectors wroteBased on medical record review, observations, and resident and staff interviews, the failed to provide a functional, and accessible call system for the residents. This affected two (Residents #12 and #16) of three residents reviewed for call light accessibility and functioning. The facility census was 37.

Inspectors wroteBased on review of the resident fund accounts, staff interviews and policy review, the facility failed to timely close one discharged resident's (#93) fund account. This affected one (#93) of five resident personal funds accounts reviewed. The census was 33.

Inspectors wroteBased on medical record review and staff interview, the facility failed to notify the state mental health authority of a change in resident's mental health status. This affected one (#22) of one resident reviewed for Pre-admission Screening and Resident Review (PASARR) during the annual survey. The facility census was 33.

Inspectors wroteBased on resident interview, staff interview, record review, and policy review, the facility failed to include residents and/or their representatives in care planning meetings and conduct quarterly care plan meetings. This affected three (#3, #8, and #29)of four residents reviewed for Care Planning during the annual survey. The facility census was 33.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure the medication error rate was less than five percent. The facility had two errors of 27 opportunities resulting in a 7.41% error rate. This affected one (#36) of six residents observed during medication pass. The facility census was 33.

Inspectors wroteBased on medical record review, physician and staff interviews, the facility failed to timely notify the physician of critical lab results. This affected one (#25) of three residents reviewed for hospitalization. The facility census was 33.

Inspectors wroteBased on observations, medical record review, menu review, resident and staff interviews, the facility failed to provide meal preferences for residents and failed to follow prepared menus for the residents. This affected one (#8) of two residents reviewed for food preferences. The facility failed to update the menus when substituting equally nutritious food and notifying residents of the changes. This affected all 33 of 33 residents who received meals form the kitchen. The facility census was 33.

Inspectors wroteBased on observation, staff interview, review of manufacture's instructions and facility policy, the facility failed to ensure the medication error rate was less than five percent. The facility had a an error rate of two of 27 opportunities resulting in a 7.41%. This affected one (#29) of six residents observed during medication pass. The facility census was 33.

Inspectors wroteBased on observation, staff interview, review of manufacture's instructions and facility policy, the facility failed ensure a resident was free from a significant medication error by not priming an insulin pen prior to preparing ordered dose. This affected one (#29) of six residents observed during medication pass. The facility identified two residents (#29 and #181) who used insulin pens. The facility census was 33.