Xenia Health and Rehab

In the surveyor’s words

From the most serious findings on record at Xenia Health and Rehab, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 7, 2024

  THE 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. […]

• No harm, potential for more than minimal, widespreadF730Jul 31, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Jul 31, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF868Jul 31, 2025

  Based 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.

• No harm, potential for more than minimal, widespreadF880Jul 31, 2025

  Based 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. […]