Xenia Health and Rehab: Medication Administration Failures - OH
Inspectors from the Centers for Medicare and Medicaid Services were watching.
The resident, identified in inspection records only as Resident 15, has lived at Xenia Health and Rehab since January 2021. By March 2026, a formal assessment documented what staff already knew: the resident was cognitively impaired and depended on staff for daily care. A physician had ordered two medications back in February, Singulair 10 milligrams once daily and a calcium and vitamin D3 combination tablet twice a day, every morning and every night.
On the morning of April 28, at 8:24, an inspector watched Registered Nurse 105 work through the medication pass for Resident 15. The nurse did not give the Singulair. The nurse did not give the calcium and vitamin D3. Ten minutes later, the inspector asked why.
The nurse confirmed it directly: neither medication was available to administer.
That was it. No medication. No explanation beyond the stock being gone. The resident, who cannot advocate for herself and depends entirely on staff to manage a complex set of chronic conditions, simply did not receive what her doctor ordered.
Singulair, the brand name for montelukast, is prescribed to manage airway inflammation in conditions like COPD. Missing doses is not a trivial gap for a patient whose lungs are already compromised. Calcium and vitamin D3 together support bone density, a concern that compounds over time, particularly for older adults who are not mobile and who depend on staff for all daily activities.
The inspection covered 33 medication administration opportunities across three residents. Two of those opportunities failed. That is a 6.06 percent error rate, both errors involving the same resident, both on the same morning, both traceable to the same cause: the medications were not there.
The complaint that triggered this inspection, filed under complaint number 2687604, was investigated alongside the medication review. The report does not describe who filed the complaint or what it originally alleged. What inspectors found when they arrived was a nurse confirming, without dispute, that a cognitively impaired resident had gone without ordered medications because no one had made sure the supply was stocked.
Xenia Health and Rehab had 27 residents at the time of the inspection. The deficiency was classified as minimal harm or potential for actual harm, the lower end of the federal harm scale. That classification reflects the regulatory judgment about documented injury, not a clinical assessment of what repeated missed doses mean for a patient managing four serious chronic conditions without the ability to notice or report the gaps herself.
The facility has not publicly responded to the findings. A plan of correction is required for continued participation in Medicare and Medicaid.
Resident 15 was not there to know her medications had run out. She was dependent on the people around her to manage that. On the morning inspectors were present, those medications were not available, the nurse confirmed it, and the observation ended.
Whether the supply had run out the day before, or the week before, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Xenia Health and Rehab from 2026-04-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
XENIA HEALTH AND REHAB in XENIA, OH was cited for violations during a health inspection on April 28, 2026.
Inspectors from the Centers for Medicare and Medicaid Services were watching.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.