A list of the most recent deficiencies for Xenia Health and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| 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. | Health | 2023-11-27 | 2023-12-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-27 | 2023-12-19 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-27 | 2023-12-19 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-11-27 | 2023-12-19 | Y |
| 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. | Health | 2023-08-03 | 2023-08-28 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-03 | 2023-08-28 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-04-21 | 2022-06-02 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2022-04-21 | 2022-06-02 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-21 | 2022-06-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-21 | 2022-06-02 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-04-21 | 2022-06-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-19 | 2022-06-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-19 | 2022-06-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-19 | 2022-06-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-19 | 2022-06-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-19 | 2022-06-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-19 | 2022-06-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-19 | 2022-06-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-18 | 2019-05-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-04-18 | 2019-05-22 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-04-18 | 2019-05-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-04-17 | 2019-05-22 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-04-17 | 2019-05-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-17 | 2019-05-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-07-03 | 2018-08-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-07-03 | 2018-08-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-07-03 | 2018-08-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-07-03 | 2018-08-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-07-03 | 2018-08-16 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-07-03 | 2018-08-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-07-03 | 2018-08-16 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-07-03 | 2018-08-16 | N |
| Provide or obtain dental services for each resident. | Health | 2018-07-03 | 2018-08-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-03 | 2018-08-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-03 | 2018-08-16 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2018-07-06 | 2018-08-16 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-07-06 | 2018-08-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-07-06 | 2018-08-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-07-06 | 2018-08-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-06 | 2018-08-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-07-06 | 2018-08-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-07-06 | 2018-08-16 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2018-07-03 | 2018-08-08 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-07-03 | 2018-08-08 | N |
