Cycle 1
Health 2025-12-11 · Fire 2025-12-11
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Xenia, OH
Atrium Nursing and Rehabilitation
2-star overall rating with 1-star inspections with $193,839 in total fines with 5 recent health deficiencies
1301 North Monroe Drive, Xenia, OH
(937) 372-4495
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
17
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hillstone Healthcare
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.50
Registered nurse staffing
LPN hours / resident day
0.31
Licensed practical nurse staffing
Aide hours / resident day
2.72
Nurse aide staffing
Weekend hours
3.98
Weekend nurse staffing
RN turnover
70%
Annual RN turnover
Total nurse turnover
74%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.3% |
92.4%
8.1 pts worse
|
93.4%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.1% |
94.5%
0.6 pts better
|
95.5%
0.4 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 37.9% |
26.1%
11.8 pts worse
|
11.4%
26.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.0% |
6.2%
6.2 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 40.0% |
25.4%
14.6 pts worse
|
19.6%
20.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 12.5% |
11.5%
1 pts worse
|
16.7%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.4% |
7.7%
2.3 pts better
|
16.3%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.1% |
6.2%
3.9 pts worse
|
14.9%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.5% |
21.7%
18.2 pts better
|
19.8%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
3.7%
3.7 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-06-26 · Fire 2025-06-26
23 health deficiencies
Top issue: Environmental (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2025-02-06 · Fire 2025-02-06
26 health deficiencies
Top issue: Nutrition and Dietary (8 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-24
F · Potential for more than minimal harm
2025-06-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-24
F · Potential for more than minimal harm
2025-06-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-24
F · Potential for more than minimal harm
2025-06-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-24
F · Potential for more than minimal harm
2025-06-26
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-07-24
F · Potential for more than minimal harm
2025-02-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-02-26
F · Potential for more than minimal harm
2025-02-06
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-02-26
F · Potential for more than minimal harm
2025-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-26
F · Potential for more than minimal harm
2025-02-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-26
F · Potential for more than minimal harm
2025-02-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-26
F · Potential for more than minimal harm
2025-02-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-11
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-12-11
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-12-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-12-11
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-12-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-31
E · Potential for more than minimal harm
2025-06-26
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-07-24
E · Potential for more than minimal harm
2025-06-26
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-07-24
E · Potential for more than minimal harm
2025-06-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-06-26
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-06-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-06-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-06-26
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-06-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-06-26
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-06-26
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-07-24
F · Potential for more than minimal harm
2025-02-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-26
F · Potential for more than minimal harm
2025-02-06
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-02-06
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-02-06
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-02-06
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-02-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-02-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-02-26
F · Potential for more than minimal harm
2024-08-14
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-09-25
F · Potential for more than minimal harm
2024-08-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-30
F · Potential for more than minimal harm
2024-08-14
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-09-25
F · Potential for more than minimal harm
2024-08-14
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-09-25
F · Potential for more than minimal harm
2024-08-14
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-09-25
J · Immediate jeopardy
2024-06-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-11
E · Potential for more than minimal harm
2024-04-02
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-06-11
G · Actual harm
2024-03-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-16
E · Potential for more than minimal harm
2024-03-14
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-06-11
E · Potential for more than minimal harm
2024-03-14
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-05-16
E · Potential for more than minimal harm
2024-03-04
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-06-11
E · Potential for more than minimal harm
2024-03-04
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-06-11
E · Potential for more than minimal harm
2024-03-04
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-05-16
J · Immediate jeopardy
2024-01-03
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-11-09
E · Potential for more than minimal harm
2024-01-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-26
E · Potential for more than minimal harm
2024-01-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-26
D · Potential for more than minimal harm
2024-01-03
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-10-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-03
F · Potential for more than minimal harm
2023-10-05
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-11-03
F · Potential for more than minimal harm
2023-10-05
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-11-03
F · Potential for more than minimal harm
2023-10-05
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-11-03
F · Potential for more than minimal harm
2023-10-05
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-05
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-05
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-11-03
F · Potential for more than minimal harm
2023-08-28
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-11-03
F · Potential for more than minimal harm
2023-08-28
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-11-03
F · Potential for more than minimal harm
2023-08-28
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-11-03
F · Potential for more than minimal harm
2023-08-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-03
J · Immediate jeopardy
2023-08-22
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-11-03
G · Actual harm
2023-04-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-19
F · Potential for more than minimal harm
2023-04-27
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-19
Penalties and ownership
What sits behind the stars
$6,500
2024-08-14
Fine
Fine · fine $6,500
Fine
$0
2024-08-14
Payment Denial
Payment Denial · denial start 2024-09-11 · 91 days
91 day denial
$128,726
2024-03-04
Fine
Fine · fine $128,726
Fine
$0
2024-03-04
Payment Denial
Payment Denial · denial start 2024-04-06 · 66 days
66 day denial
$15,887
2024-01-03
Fine
Fine · fine $15,887
Fine
$42,726
2023-08-22
Fine
Fine · fine $42,726
Fine
$0
2023-08-22
Payment Denial
Payment Denial · denial start 2023-09-14 · 50 days
50 day denial
Ownership
Allen, Crystal
Operational/Managerial Control · Individual
Ausch, Chaim
Operational/Managerial Control · Individual
Berner, Susan
Operational/Managerial Control · Individual
Eminent Care Group LLC
Operational/Managerial Control · Organization
Geldzahler, Yaakov
Operational/Managerial Control · Individual
S & T Bank
5% Or Greater Mortgage Interest · Organization
Smith, Jazmaine
Operational/Managerial Control · Individual
Zserebrowski, Yechezkel
Operational/Managerial Control · Individual
Nearby options
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#3
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