Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aventura At Shiloh Springs during CMS and state inspections, most recent first.
A facility failed to ensure safe smoking supervision and that residents smoked only in designated areas. One resident with bipolar disorder and other diagnoses was observed smoking in front of the facility after signing out, with no staff outside, despite being directed to smoke in designated areas. Another resident with COPD and tobacco use was observed smoking alone in the smoking area even though the smoking assessment required supervision; the DON confirmed staff should have been supervising, but the resident was not visible to staff.
Unclean Resident Rooms and Equipment: Two residents’ rooms were observed with scattered dirt, black residue along wall edges, and spilled or dried enteral feed on the floor and tube feed pole. A CNA and HA both verified the areas were still unclean after mopping and sweeping, and the HA stated she did not clean under one resident’s bed because her broom or mop handle would hit the bed.
A resident with multiple medical and psychiatric diagnoses, but intact cognition, had a physician order entered in the record stating they may not go on LOA, which conflicted with the physician’s actual verbal order allowing LOA only with supervision. The ADON entered the no-LOA order after overhearing a phone conversation between the Administrator and the physician, without receiving or reading back the order directly to the physician as required by facility policy. The discrepancy was later discovered when the Ombudsman questioned the order, revealing that the facility failed to accurately transcribe and verify the physician’s verbal order regarding the resident’s LOA status.
Failure to Submit PBJ Staffing Data: The facility failed to submit PBJ staffing information to CMS as required. Review of the PBJ Staffing Data Report showed that staffing data for a quarter of FY 2025 was not submitted, and corporate HR verified receiving an alert for the late submission. The issue had the potential to affect all 55 residents in the facility.
A resident with multiple medical conditions, including diabetes and osteomyelitis, was receiving scheduled oxycodone, a narcotic analgesic associated with constipation risk. The medical record contained no documentation of bowel movement monitoring or of the resident’s last bowel movement, despite this risk. The resident reported not having a bowel movement for 10 days and felt that any treatment provided was not effective. The Administrator confirmed the absence of bowel movement documentation, leading surveyors to cite a deficiency for failure to provide appropriate monitoring and care related to constipation.
A resident with multiple medical conditions, including bacteremia and diabetes, had a physician order for a Foley catheter to be clamped over a 24-hour period and then discontinued, with specific instructions for straight catheterization and possible Foley replacement based on post-void residuals. Record review showed no documentation that staff removed or attempted to remove the Foley as ordered, and the catheter remained in place. The resident later presented with abnormal vital signs and was sent to the ER, and interviews with the Administrator and DON confirmed there was no documentation of Foley removal or attempts, despite the DON believing it had been removed and reinserted.
Inaccurate and Missing Care Plans for Foley, Dialysis, and Constipation Needs: The facility failed to ensure care plans reflected the needs of three residents. One resident had a Foley catheter and narcotic pain medication orders, but the care plan had no related goals or interventions. Another resident with ESRD and dialysis dependence had no documented person-centered dialysis care plan. A third resident with repeated constipation treatment orders had no documented comprehensive constipation care plan; the DON confirmed the missing care plans.
Improper Tracheostomy Care: An LPN provided trach care to a resident with COPD, CAD, hemiplegia, encephalopathy, and psychotic disturbance without proper hand hygiene or sterile technique. She removed gloves from prior care, did not sanitize hands, did not wear a gown or facemask, touched non-sterile items with sterile gloves, suctioned the trach, and replaced the inner cannula using the same gloves.
Dialysis Care Documentation and Communication Failures: A resident with ESRD and dependence on dialysis had multiple refused, missed, and incomplete HD treatments, but the record lacked documentation explaining missed treatments, pre- and post-dialysis evaluations, consistent communication with the dialysis center, and physician notification of missed HD. The DON confirmed the missing documentation, and the dialysis nurse reported the resident had a history of refusing or not completing treatments.
Medication Left at Bedside: A resident with atrial fibrillation, HF, HTN, malnutrition, and PTSD had pills in a medication cup and a bottle of Flonase left on the bedside table. The resident was cognitively intact, had no order or care plan for self-administration, and an LPN confirmed the medications were present at the bedside and was unsure when they had been left there.
Failure to obtain ordered lab tests affected three residents. One resident with ESRD and dialysis had weekly CBC/CMP orders, but the record only showed a refusal on one date and no documentation of other attempts that month. Another resident with COPD, bipolar disorder, DM, and HTN had weekly CBC/BMP orders, but the record lacked documentation that the labs were obtained or attempted except once. A third resident with bacteremia, cellulitis, DM2, and osteomyelitis had a CBC order after abnormal labs were reviewed; the specimen was clotted, and there was no documentation of a re-draw or physician notification. The DON confirmed the missing documentation.
Failure to follow EBP during resident care. A resident with a trach and feeding tube had orders for EBP, but an LPN provided feeding tube meds and deep suctioning without donning a gown and without a facemask during suctioning. The facility policy required gown and glove use for high-contact care activities, including device care such as feeding tube and trach care.
Two residents were observed smoking outside of designated areas, with one smoking unsupervised near the main entrance despite requiring supervision, and another smoking in the parking lot instead of off facility property as required. Staff confirmed that smoking materials were provided and stored by nursing staff, but supervision and adherence to designated smoking areas were not maintained. Additionally, cigarette butts were found discarded in multiple inappropriate locations, despite the availability of non-combustible containers.
A facility failed to notify the physician or family of a newly identified pressure ulcer in a resident with intact cognition and multiple diagnoses, including diabetes and hypertension. Upon admission, no pressure ulcers were documented, but a later assessment revealed a significant unstageable sacral pressure wound. The facility's policy required notification of such changes, but this was not done, as confirmed by the DON.
A facility failed to provide adequate assistance with personal hygiene and ADLs for a resident requiring moderate assistance. Despite having a care plan for toileting and incontinence care, the resident received only one bed bath during her stay. A physical therapist noted multiple instances where the resident was found saturated and unable to receive timely assistance from CNAs, impacting therapy sessions. The DON confirmed the lack of documentation for additional showers or baths.
The facility failed to provide appropriate care for pressure ulcers for two residents. One resident developed an unstageable sacral pressure wound that was not treated promptly, and the wound physician's orders were not followed correctly. Another resident had unstageable pressure wounds on both heels, but there was a lack of documentation and delayed treatment. The facility's policy for pressure sore assessment was not adhered to.
A resident admitted with orders for PT and OT services did not receive timely evaluations, with PT delayed and OT never conducted. The facility's expectation for therapy screening within 48 to 72 hours was not met, as confirmed by staff interviews.
A facility failed to follow proper infection control procedures during the care of a resident with significant impaired cognition and multiple health conditions. An LPN was observed applying multiple layers of gloves and not performing hand hygiene between glove changes, contrary to the facility's policy. This incident was noted during a complaint investigation.
Two residents' rooms were found in unsanitary conditions, with dirty floors, black dirt around wall edges, and a leaking bathroom sink. One resident, with severe cognitive impairment, had a room with stained floors and circular marks, while another cognitively intact resident had a very dirty floor and a dripping sink. The facility's policy on maintaining a clean and homelike environment was not followed.
A resident with multiple health conditions experienced a delay in assistance due to a call light being obscured by an unlatched fire door. The CNA took 20 minutes to respond, exceeding the facility's 15-minute response policy. The DON confirmed the expected response time, while the Regional Administrator was unaware of the door issue.
A resident with multiple diagnoses, including cellulitis and acute kidney failure, did not receive timely pain medication as ordered. Despite the resident's request and reporting a high pain level, an LPN failed to administer oxycodone IR 5 mg due to lack of access to the emergency drug kit. The medication was available, but the LPN did not have the necessary key, leading to a delay in pain management.
A resident with type two diabetes was not adequately monitored for blood glucose levels, affecting the administration of sliding scale insulin. The resident had a continuous glucose monitoring device, but an LPN failed to check the glucose levels or administer insulin as prescribed. The LPN documented refusals without verifying the resident's glucose levels, and the DON was unaware of this non-compliance.
A facility failed to accurately document medication administration records for a resident with diabetes, affecting their blood glucose monitoring and insulin administration. An LPN did not check the resident's blood glucose levels or verify the need for insulin, despite having a continuous glucose monitoring device. The resident confirmed the LPN did not visit them for insulin administration, and their blood glucose reading was 279 mg/dL. This deficiency was found during a complaint investigation.
The facility failed to document the administration of as-needed medication and care services for three residents, leading to deficiencies in medical record accuracy. A resident's incontinent care was not documented as per the care plan, another resident's BiPap device application was not recorded despite physician orders, and a third resident's Tylenol administration for pain was not reflected in the MAR, despite LPNs confirming its administration. The DON verified these documentation lapses.
A resident was physically abused by two other residents in a LTC facility. The incident involved one resident being struck in the face with a cane and then hit in the head from behind. The facility's investigation confirmed the abuse, with admissions from the involved residents. The affected resident had moderate cognitive impairment and required assistance for daily activities. The facility's failure to prevent this abuse was noted as non-compliance.
A resident with cognitive impairment and a history of wandering eloped from the facility in a wheelchair, despite being identified as at risk and requiring one-on-one monitoring. The facility's care plan and elopement policy were not effectively implemented, leading to the resident's unsupervised exit.
A facility failed to administer medications timely, affecting a resident's scheduled doses. An LPN was observed administering medications late, including gabapentin, which was supposed to be given three times daily at specific times. The delay was acknowledged by the LPN, impacting the timing of subsequent doses. This action was contrary to the facility's policy requiring timely medication administration.
Failure to Supervise Residents During Smoking
Penalty
Summary
The facility failed to ensure staff provided the necessary level of supervision for safe smoking and failed to ensure residents smoked only in designated smoking areas. Resident #29 had diagnoses including displaced fracture of the fifth cervical vertebra, hallucinations, bipolar disorder, panic disorder, and muscle weakness. Although the resident was cognitively intact and the smoking assessment indicated he did not require supervision while smoking, the care plan identified him as at risk for side effects or injury from smoking and directed that he smoke in designated areas. After signing himself out of the facility, he was observed smoking under the overhang door near the front entrance, which was an unused door, with no staff outside. The resident confirmed he was smoking in front of the facility, and the Administrator and Receptionist stated he had smoked there before and had been educated not to do so. The Administrator later stated residents were expected to go off facility property when they signed themselves out to smoke. Resident #41 had diagnoses including type II diabetes mellitus without complication, chronic obstructive pulmonary disease, and tobacco use. The resident was cognitively intact, the smoking assessment indicated she required supervision, and the care plan stated she was at risk for injury related to smoking and would be supervised while smoking. During observation, she was smoking alone in the designated smoking area. The DON confirmed residents had designated smoking times and should have a staff member supervising them, but Resident #41 was actively smoking and not visible to staff. An Activities Aide stated she could not see the resident because the view was obstructed by a tree. The facility policy stated smoking was only allowed in designated smoking areas and that any resident requiring monitoring must have direct staff supervision at all times while smoking.
Unclean Resident Rooms and Equipment
Penalty
Summary
The facility failed to maintain residents’ floors and medical equipment in a clean manner for two residents, Resident #38 and Resident #40. During observation, Resident #40’s room floor was wet from recent mopping and had specks of unknown black dirt on the cream-colored floor, heavy dirt including hair under the bed, a speck of unknown dirt against the wall and floor, large spots of enteral feed spilled on the floor and tube feed pole, and four tan stains in the center of the floor that appeared similar in color to the enteral feed. The CNA caring for Resident #40 stated that enteral feed gets spilled and gets stuck on the floor and verified the floor had dirt and unclean areas. In Resident #38’s room, the Housekeeping Aid stated the room had just been mopped and swept, but there was scattered black unknown dirt on the floor, an unknown black substance along the wall edges, and dirt that could be moved by moving a shoe around the floor. The Housekeeping Aid also verified the floor was not swept well. The same Housekeeping Aid later stated Resident #40’s floor had just been swept and mopped but still had scattered dirt, dried enteral feed under the tube feed pole, and the four tan stains in the center of the floor, and she said she had not mopped or swept under the bed because her broom or mop handle would hit the bottom of the bed. The LTCO stated residents had complained about rooms being clean, and the facility policy required a clean and healthy environment, including cleaning floors and cleaning behind and underneath beds every other day.
Mis-transcribed Verbal Order Resulting in Incorrect LOA Restriction
Penalty
Summary
The deficiency involves the facility’s failure to ensure physician orders were accurately transcribed, resulting in an incorrect restriction on a resident’s leave of absence (LOA). The resident, admitted with diagnoses including syncope and collapse, asthma, diabetes, cocaine abuse in remission, drug-induced subacute dyskinesia, bradycardia, anxiety, depression, and PTSD, had intact cognition and required varying levels of assistance with ADLs. A physician order dated 01/28/26 in the medical record stated the resident "may not go on leave of absence (LOA)." However, the resident subsequently went on an LOA with family on 03/01/26. The resident reported learning of the no-LOA order when being loaded onto a transport van to go out for food and being told by staff she was not allowed to leave. The Assistant Director of Nursing (ADON) documented a progress note on 01/28/26 indicating a new order that the resident was not to go on LOA while under the facility’s care, related to finding empty bottles of narcotics that had recently been filled by other pharmacies. The ADON stated she entered the order after a phone conversation between the Administrator and the physician, during which she could hear the physician’s voice but did not hear the specific orders. She acknowledged she should only take orders directly from a physician and did not clarify the order directly with the physician, and later became aware the order did not match what the physician had said when questioned by the Ombudsman. The physician reported he had given a verbal order allowing LOA only with supervision and denied ordering that the resident not be allowed LOA at all. Facility policy on verbal orders required the individual receiving the verbal order to read the order back to the practitioner to ensure it was clearly understood and correctly transcribed, which did not occur in this case.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to submit the Payroll Based Journal (PBJ) staffing information to CMS as required. Review of the PBJ Staffing Data Report [NAME] Report 1705D FY Quarter 3 2025 (April 1 - June 30) dated 12/26/25 revealed that staffing data for the quarter was not submitted. During an interview with Corporate Human Resources (CHR #300) on 01/08/26 at 2:25 P.M., corporate staff verified that they had received an alert notifying them of a late submission for one of the quarters of fiscal year 2025. The deficiency had the potential to affect all 55 residents residing in the facility, and the facility census was 55.
Failure to Monitor Bowel Movements for Resident on Narcotic Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to monitor bowel movements for a resident at risk of constipation while receiving narcotic pain medication. The resident was admitted with diagnoses including bacteremia, hypertension, cellulitis, type 2 diabetes mellitus, and osteomyelitis, and a quarterly MDS documented that the resident was cognitively intact. Physician orders included oxycodone hydrochloride 5 mg by mouth four times a day for pain, a medication known to potentially cause constipation. Despite this risk, review of the medical record showed no documentation that the resident’s bowel movements were being monitored and no record of the date of the last bowel movement. During an interview, the resident reported it had been 10 days since having a bowel movement and stated they believed they had been given something to help but did not think it was effective. The Administrator confirmed there was no documentation of bowel movement monitoring for this resident. Reference materials reviewed by surveyors, including Medscape and MedlinePlus, indicated that oxycodone may cause constipation and that a medical provider should be contacted if a person has not had a bowel movement in three days. This lack of monitoring and documentation for a resident at risk of constipation formed the basis of the cited deficiency.
Failure to Follow Foley Catheter Discontinuation Order
Penalty
Summary
The facility failed to follow a physician’s order to attempt removal of an indwelling Foley catheter for a resident. The resident was admitted with diagnoses including bacteremia, hypertension, cellulitis, type 2 diabetes mellitus, and osteomyelitis, and a quarterly MDS indicated the resident was cognitively intact. A physician’s order dated 12/30/25 directed staff to clamp the Foley catheter for four hours, release for 15 minutes, repeat for 24 hours, then discontinue the Foley. The order further specified that if the resident did not void, staff could perform straight catheterization every four to six hours and as needed, and if the post-void residual exceeded 500 milliliters twice, the Foley should be replaced. Review of the medical record showed no documentation that the Foley catheter was removed or that removal was attempted as ordered on 12/20/26. Progress notes instead showed that the Foley was removed on 01/06/25 per order, and the resident was sent to the ER for elevated temperature, elevated pulse, and decreased blood pressure. During an observation and interview, the resident was noted to have an indwelling Foley in place and reported that a nurse had told him the Foley “didn’t look right.” In an interview, the Administrator and DON confirmed there was no documentation of the Foley being removed or of any attempt to remove it, and the DON stated she thought the Foley had been removed and reinserted but acknowledged there was no documentation. This constituted a failure to ensure appropriate Foley catheter care as ordered.
Inaccurate and Missing Care Plans for Foley, Dialysis, and Constipation Needs
Penalty
Summary
The facility failed to ensure resident care plans were accurate and reflected resident needs for three residents reviewed. Resident #2 was admitted with diagnoses including bacteremia, hypertension, cellulitis, type 2 diabetes mellitus, and osteomyelitis, was cognitively intact, had a Foley catheter in place from admission until 01/06/26, and had been ordered oxycodone since admission, but the care plan initiated 12/04/25 contained no focus, goals, or interventions related to the Foley catheter or narcotic medication use. The DON confirmed the care plan did not include these items. Resident #03 was admitted with intracranial hemorrhage, left hemiparesis, ESRD, and dialysis dependence. The quarterly MDS indicated the resident was cognitively intact, required partial/moderate assistance with toilet hygiene and showers, supervision with transfers, was independent with bed mobility, and received dialysis, with an order for dialysis at a center on Monday, Wednesday, and Friday; however, there was no documentation that the facility developed a comprehensive person-centered dialysis care plan. Resident #65 was admitted with a wedge compression fracture of the lumbar vertebra, asthma, and convulsions, had an MDS showing cognitive intactness and varying levels of assistance with bathing, toilet hygiene, transfers, and eating, and had multiple physician orders for constipation treatment including docusate sodium, MiraLAX, an enema, and Colace, but there was no documentation of a comprehensive person-centered care plan for constipation. The DON confirmed Resident #03 did not have a dialysis care plan and Resident #65 did not have a constipation care plan.
Improper Tracheostomy Care
Penalty
Summary
The facility failed to ensure safe and appropriate tracheostomy care for Resident #10, who was admitted on 01/21/25 and had diagnoses including COPD, CAD, anxiety disorder, hemiplegia, encephalopathy, and psychotic disturbance. The quarterly MDS indicated the resident was rarely understood by staff and received trach care. During observation of tracheostomy care, LPN #201 removed gloves used during feeding tube care and did not sanitize or wash hands before beginning the trach procedure. She opened the trach care pack, poured sterile water into the sterile box, and donned sterile gloves, but did not put on a gown or facemask. During the procedure, LPN #201 touched the suction machine with sterile gloves, removed the resident’s inner trach cannula with her left hand, and used the same sterile gloves to guide the suction catheter into the trach and suction three times, clearing the tubing with sterile water each time. She then replaced the inner cannula using the same gloves and did not change gloves or maintain sterility during the procedure. On interview, LPN #201 confirmed she did not wear a gown or facemask and did not wash or sanitize her hands between glove changes, and she used sterile gloves while touching non-sterile items during the trach care.
Dialysis Care Documentation and Communication Failures
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care/services for one resident who required dialysis. The resident was admitted with intracranial hemorrhage, left hemiparesis, ESRD, and dependence on dialysis. The quarterly MDS dated 12/18/25 indicated the resident was cognitively intact, independent with bed mobility, and required partial/moderate assistance with toilet hygiene and showers, with supervision for transfers. The resident had a physician order for dialysis on Monday, Wednesday, and Friday at a dialysis center with an 11:45 A.M. chair time. Review of the December 2025 TAR and dialysis center logs showed the resident received dialysis as scheduled on some days, but also refused dialysis on several dates, missed treatments, did not complete full treatments, and had treatments rescheduled. The medical record did not contain documentation explaining why dialysis was not received on 12/21/25 or 12/23/25, and there was no documentation that the facility notified the physician of missed dialysis treatments or completed pre- and post-dialysis evaluations. Only one dialysis communication form was found for December, documenting that the resident did not receive a full dialysis treatment; no other communication forms for December or January 2025 were completed by the facility. The DON confirmed the record lacked documentation of pre/post dialysis evaluations, communication with the dialysis center, physician notification of missed treatments, and documentation related to missed or partial treatments. The dialysis nurse also stated the resident had a history of refusing or not completing dialysis, and confirmed the resident had not returned to the dialysis center after refusing treatment and being told stat potassium levels were needed before returning.
Medication Left at Bedside
Penalty
Summary
The facility failed to ensure medications were not left at a resident's bedside and that drugs and biologicals were stored in accordance with accepted professional principles. Resident #50 was admitted on 09/18/25 and had diagnoses including atrial fibrillation, heart failure, hypertension, malnutrition, and post-traumatic stress disorder. A quarterly MDS dated [DATE] indicated the resident was cognitively intact, and the medical record showed nursing staff were to administer medications, with no assessment, order, or care plan for self-administration. During observation on 01/05/26 at 11:22 A.M., several pills in a medication cup and a bottle of Flonase were seen on the resident's bedside table. An LPN confirmed 14 pills in a medication cup and a bottle of Flonase on the bedside table at 11:25 A.M., denied leaving them there, and was unsure when they had been left. The resident stated he believed they had been left there from the morning. The facility policy stated medications and biologicals are to be stored in the packaging, containers, or dispensing systems in which they are received, and only the issuing pharmacy is authorized to transfer medications between containers.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure laboratory values were obtained as ordered by the physician for three residents reviewed for lab services. Resident #03 had diagnoses including intracranial hemorrhage, left hemiparesis, ESRD, and dependence on dialysis. A physician order required CBC and CMP weekly and faxed to the dialysis center every Monday, but the record showed the resident refused CBC and BMP on 12/22/25 and there was no documentation that the facility obtained or attempted to obtain the CBC and BMP on any other dates in December 2025. Resident #09 had diagnoses including COPD, bipolar disorder, diabetes mellitus, and hypertension. A physician order required weekly CBC and BMP, but the record contained no documentation that the facility obtained or attempted to obtain the labs in November 2025 except on 11/20/25. Resident #02 was admitted with bacteremia, hypertension, cellulitis, type 2 diabetes mellitus, and osteomyelitis. After progress notes documented review of lab values with the NP and a new order for a stat chest X-ray and CBC on the next lab day, the CBC specimen obtained on 12/31/25 was clotted and reported on 01/01/26. The record contained no documentation that the CBC was re-drawn or that the physician was notified. The DON confirmed the records for Residents #03, #09, and #02 did not contain documentation supporting that labs were obtained as ordered.
Failure to Follow Enhanced Barrier Precautions During Tracheostomy and Feeding Tube Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff failed to follow enhanced barrier precautions for a resident with a tracheostomy and feeding tube. Resident #10 was admitted on 01/21/25 and had diagnoses including chronic obstructive pulmonary disease, coronary artery disease, anxiety disorder, hemiplegia, encephalopathy, and psychotic disturbance. The quarterly MDS dated [DATE] indicated the resident was rarely understood by staff and received tracheostomy care. Physician orders dated 09/24/25 directed enhanced barrier precautions because of the tracheostomy and feeding tube. During observation on 01/07/2026 at 2:05 P.M., LPN #201 provided medication administration through the feeding tube and completed trach care, including deep suctioning, without donning a gown. The LPN also did not don a facemask while performing deep suctioning. During interview on 01/12/26 at 2:20 P.M., LPN #201 confirmed she did not wear a gown during the resident's care and stated there was a sign posted at the room entrance informing staff of enhanced barrier precautions. The facility policy titled Enhanced Barrier Precautions dated December 2024 stated that gowns and gloves are to be used during high-contact resident care activities, including device care or use such as feeding tube and tracheostomy care.
Failure to Supervise Resident Smoking and Enforce Designated Smoking Areas
Penalty
Summary
The facility failed to ensure that residents who smoked were properly supervised and that smoking occurred only in designated areas, as required by facility policy. Observations revealed that one resident, who was assessed as requiring supervision while smoking, was seen smoking unsupervised near the facility's main entrance, despite a posted no smoking sign. Staff interviews confirmed that this resident was supposed to be supervised and to smoke only in the designated area, with smoking materials stored by staff. The resident confirmed that staff provided him with his smoking supplies that morning, but he proceeded to smoke unsupervised outside the main entrance. Another resident, who was assessed as safe to smoke without direct supervision, was observed smoking in the facility's parking lot rather than in the designated smoking area or off facility property, as required by policy. This resident acknowledged awareness of the rule to smoke off facility property and confirmed that staff kept his smoking supplies at the nurses' station. Staff interviews corroborated that residents not requiring supervision were expected to smoke off facility property, but this was not being followed. Additionally, multiple cigarette butts were observed discarded on the ground along the sidewalk, in the parking lot, and in the mulch at the facility's entrance and in the designated smoking area. Although a non-combustible container was available for disposal, cigarette butts were found in inappropriate locations, indicating that residents were not consistently using the proper containers to extinguish smoking materials. These findings demonstrate a failure to maintain safe smoking practices and adequate supervision as outlined in the facility's smoking policy.
Failure to Notify Physician and Family of Pressure Ulcer
Penalty
Summary
The facility failed to notify the physician or family of a newly identified pressure ulcer for a resident. The resident, who had intact cognition and required moderate assistance for certain activities, was admitted with diagnoses including bilateral osteoarthritis, type two diabetes mellitus, and hypertension. Upon admission, there were no pressure ulcers documented. However, a skin assessment conducted on 02/06/25 revealed a nine by eleven centimeter unstageable sacral pressure wound. The notification section of the assessment document lacked any indication that the physician or family had been informed of this significant change in the resident's condition. An interview with the Director of Nursing confirmed that neither the physician nor the family had been notified of the pressure ulcer upon its discovery. The facility's policy required notification of the physician and resident representative in the event of changes in a resident's medical condition, which was not adhered to in this case.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with personal hygiene and Activities of Daily Living (ADL) for a resident, identified as Resident #10, who required moderate assistance with these tasks. The resident, who had intact cognition and was admitted with diagnoses including bilateral osteoarthritis, type two diabetes mellitus, and hypertension, was found to have received only one bed bath during her stay from early February until her hospitalization later that month. The care plan for the resident included interventions for assistance with toileting needs and incontinence care, but these were not adequately implemented. The deficiency was further highlighted by a physical therapy note indicating that on multiple occasions, the resident was found saturated and in need of cleaning, but nursing aides were not available to assist in a timely manner. The Director of Nursing confirmed the lack of documentation for additional showers or baths, and a physical therapist reported difficulty in locating CNAs to assist the resident, which impacted the therapy sessions. This lack of timely assistance and documentation represents a failure in providing necessary care for the resident's hygiene and ADL needs.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care and services for pressure ulcers for two residents. Resident #10 was admitted with no pressure ulcers but developed an unstageable sacral pressure wound measuring 9 cm by 11 cm, which was not treated until three days after it was discovered. The wound physician's orders for daily dressing changes were not followed correctly, as the facility implemented a different dressing and frequency than prescribed. The Director of Nursing (DON) confirmed these discrepancies and acknowledged that the wound physician's orders were not followed as written. Resident #11, who had impaired cognition, was found to have unstageable pressure wounds on both heels during a readmission skin assessment. However, there were no measurements or detailed assessments documented for these wounds. Treatment orders were delayed by two days, and subsequent skin assessments failed to document the presence of these wounds. The DON verified the lack of documentation and measurements for Resident #11's wounds and acknowledged that the issue would be addressed. The facility's policy required a full assessment of pressure sores, including location, stage, and measurements, which was not adhered to in these cases.
Failure to Provide Timely Therapy Services
Penalty
Summary
The facility failed to provide timely therapy services to a resident, which was identified during a review of medical records, hospital referrals, and staff interviews. The resident, who was admitted with diagnoses including bilateral osteoarthritis, type two diabetes mellitus, and hypertension, had orders for both Physical Therapy (PT) and Occupational Therapy (OT) services to continue after discharge from the hospital. Despite these orders, the resident was not evaluated by PT until several days after admission, and OT services were never provided. Interviews with the Therapy Manager and the Administrator revealed that the facility's expectation was for residents to be screened for therapy services within the first 48 to 72 hours of admission. However, due to an oversight, the resident did not receive the necessary evaluations in a timely manner. The Therapy Manager could not recall the specifics of the resident's needs, and the Administrator confirmed the delay in PT evaluation and the absence of OT evaluation. This deficiency was investigated under specific complaint numbers.
Infection Control Deficiency During Resident Care
Penalty
Summary
The facility failed to ensure proper infection control procedures were followed during the care of a resident, which was observed during a complaint investigation. The resident, who was admitted with conditions including hemiplegia, diabetes mellitus, depression, and a gastronomy tube, was also on hospice care and had significant impaired cognition. The resident was dependent on staff for various activities, including eating, bed mobility, transfers, and toileting hygiene, and was always incontinent of urine and bowel. During an observation of wound care, the resident was found to be incontinent, and the LPN left the room to gather supplies. Upon returning, the LPN washed her hands and applied multiple layers of gloves before proceeding with the care. During the wound care process, the LPN removed the top layer of gloves after cleansing the resident's buttocks and continued to remove additional layers of gloves without performing hand hygiene between glove changes. The facility's policy required staff to remove disposable gloves, discard them, and wash and dry hands thoroughly, which was not followed in this instance. The LPN acknowledged that hand hygiene was not performed during the observation or after removing multiple layers of gloves, which was against the facility's infection control policy.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, affecting two residents' rooms. Resident #34, who has chronic diastolic heart failure, cognitive communication deficit, atrial flutter, and hypertension, was observed to have a room with a dirty and stained floor. The floor had 25 circular brownish-black marks, and the wall edges were covered with black, hard dirt extending two to three inches into the room. Housekeeping Aide #236 confirmed the difficulty in cleaning the floor, suggesting the presence of old floor wax. Resident #34, assessed with severely impaired cognition, verified the floor's condition. Resident #13, diagnosed with type two diabetes, alcohol dependence, bipolar disorder, major depressive disorder, acute kidney failure, and hypertension, was found to have a very dirty floor with large circular wear patterns and black, hard dirt around the wall edges. The Housekeeping Director confirmed these observations and noted a continuous drip from the bathroom sink onto brown paper towels. Resident #13 was assessed as cognitively intact. The facility's policy on providing a safe, clean, and homelike environment was not adhered to, as evidenced by the conditions in these residents' rooms.
Delayed Response to Call Light Due to Obstructed View
Penalty
Summary
The facility failed to provide timely care and services in response to call lights, specifically affecting Resident #29. The resident, who has diagnoses including bipolar disorder, type two diabetes, morbid obesity, anxiety, and major depression, was assessed with intact cognition and required assistance with various activities of daily living (ADLs). On the morning of January 22, 2025, Resident #29 activated the call light while in the bathroom needing assistance. However, the call light was not answered until 20 minutes later by CNA #278. The delay was attributed to the call light being obscured by an opened fire door, which was unlatched and blocked the view of the call light. Interviews with staff and the resident confirmed the delay in response. CNA #278 acknowledged the delay and attributed it to the obscured call light. The Director of Nursing stated that call lights should be answered within 15 minutes, while the Regional Administrator was unaware of the fire door's malfunction. The facility's policy on answering call lights requires staff to respond promptly and indicate the time it will take to assist the resident. This deficiency was investigated under Complaint Number OH00161139.
Failure to Provide Timely Pain Medication
Penalty
Summary
The facility failed to provide timely pain medication to Resident #3, who was admitted with diagnoses including cellulitis, acute kidney failure, major depressive disorder, and hypertension. The resident had a physician's order for oxycodone IR 5 mg to be taken every eight hours as needed for pain. On the morning of January 22, 2025, the resident requested the medication from LPN #292, who informed the resident that she needed to contact the pharmacy regarding the delivery status of the medication. However, the medication was not administered, and the resident reported a pain level of seven out of ten later that afternoon, stating he had not received the medication for two days. Further investigation revealed that the oxycodone IR 5 mg was available in the facility's emergency drug kit, but LPN #292 did not have access to the narcotic locked cart. The Director of Nursing later confirmed the availability of the medication in the emergency supply and facilitated its administration. LPN #228 acknowledged that LPN #292 should have accessed the emergency supply earlier in the day when the resident requested the medication. This deficiency was identified during a complaint investigation under Complaint Number OH00161139.
Failure to Monitor Blood Glucose Levels for Insulin Administration
Penalty
Summary
The facility failed to ensure that blood glucose levels were adequately monitored for a resident with type two diabetes, which affected the administration of sliding scale insulin. Resident #13, who was cognitively intact, had a continuous glucose monitoring device, the FreeStyle Libre 2 Sensor, to monitor blood glucose levels. The resident was prescribed Humalog insulin to be administered based on specific blood glucose readings. However, the medical administration record (MAR) showed that the resident refused insulin doses on multiple occasions without documented evidence of blood glucose levels being checked. Licensed Practical Nurse (LPN) #292 admitted to not checking the resident's blood glucose levels or knowing the location of the resident's glucose monitor. The LPN documented that the resident refused insulin without verifying the blood glucose levels, which was confirmed by the resident who stated that the LPN did not visit him for insulin administration or glucose level checks. The Director of Nursing (DON) was unaware of the staff's failure to monitor the resident's blood glucose levels as ordered, acknowledging that this was not acceptable practice.
Failure to Document Blood Glucose Monitoring and Insulin Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration records for a resident with type two diabetes, affecting their blood glucose monitoring and insulin administration. The resident, who was cognitively intact, had a continuous glucose monitoring device, the FreeStyle Libre 2 Sensor, which was to be used to monitor blood glucose levels. Despite having a physician's order for sliding scale Humalog insulin based on specific blood glucose levels, the medication administration record showed that the resident was documented as refusing insulin doses on two consecutive days without any evidence of blood glucose levels being checked. An LPN admitted to not checking the resident's blood glucose levels or asking the resident for their blood glucose reading, despite the presence of the monitoring device. The LPN documented that the resident refused insulin without verifying the blood glucose level, which was necessary to determine the need for insulin administration. The resident confirmed that the LPN did not visit them to check their blood glucose level or administer insulin, and at the time of observation, the resident's blood glucose reading was 279 mg/dL. This deficiency was identified during an investigation of a complaint.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to document the administration of as-needed medication and care services for three residents, leading to deficiencies in medical record accuracy. For Resident #45, the facility did not document incontinent care as per the plan of care, which included assistance with toileting needs and incontinence care on routine rounds. The Director of Nursing (DON) confirmed that the task was not triggered for the State tested Nursing Assistant (STNA) to document, and no other documentation was found to indicate that the care was provided. Resident #18's medical records lacked documentation related to the application of a BiPap device at bedtime, despite having physician orders for its use. The DON verified that the treatment administration record was silent on this matter and acknowledged that the orders were not added to the electronic health record after the resident returned from the hospital. The facility's policy required documentation of the general assessment and specifics of the CPAP/BiPap use, which was not adhered to. For Resident #15, the Medication Administration Record (MAR) did not reflect the administration of Tylenol for pain management, despite interviews with two Licensed Practical Nurses (LPNs) confirming they had administered the medication. The DON verified the absence of documentation and noted that the nurses would make a late entry regarding the administration. Additionally, there was no independent order for pain monitoring every shift, which was later added to the resident's medication profile.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse, resulting in an incident where a resident was struck by two other residents. Resident #19 reported being hit in the face with a cane by Resident #41 and then being struck in the head from behind by Resident #52. This incident was initially denied by the accused residents, but Resident #52 later admitted to the act, and Resident #41 confessed during a subsequent interview. The facility's self-reported incident and investigation revealed these events, which affected Resident #19, who had moderate cognitive impairment and required substantial assistance for daily activities. Resident #19, who had a history of behavior problems and was disruptive, was sent to the hospital following the incident with complaints of seeing black dots after the head trauma but returned with no new diagnosis. Resident #41, who had a history of major depressive disorder and behavioral issues, was also sent to the hospital after the incident. Resident #52, diagnosed with multiple sclerosis and depression, was involved in the altercation and was sent to the hospital as well. The facility's policy on preventing and addressing elder abuse was reviewed, highlighting the purpose of preventing and prosecuting elder abuse and neglect. The Director of Nursing confirmed the details of the incident, acknowledging that Resident #41 used a metal cane to hit Resident #19 and that Resident #52 struck Resident #19 from behind. The facility's failure to prevent this abuse represents non-compliance with regulations, as investigated under a specific complaint number. The report does not mention any corrective actions or follow-up measures taken by the facility to address the deficiency.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent the elopement of a resident, identified as Resident #24, who was at risk for wandering due to cognitive impairment. The resident had been admitted with diagnoses including Wernicke's encephalopathy and altered mental status, and was noted to be cognitively impaired, requiring maximal assistance with activities of daily living. A Wander Risk Evaluation conducted on 02/02/24 identified the resident as at risk for wandering, but no interventions were care planned at that time. The care plan later included interventions such as observing for signs of planning to leave and redirecting the resident, but these measures were not effectively implemented. On 05/27/24, Resident #24 eloped from the facility in a wheelchair through the 100 hallway door, shortly after receiving evening medications. The alarm alerted staff, and the resident was found outside the facility and returned to his room. The Director of Nursing confirmed that the resident should have been on one-on-one monitoring since 03/20/24, as per the care plan, but this was not adhered to. The facility's policy on elopement indicated that residents should be placed on one-on-one monitoring after an elopement until the interdisciplinary team meets, but this was not followed, leading to the deficiency.
Medication Administration Delay
Penalty
Summary
The facility failed to ensure timely administration of medications, affecting one resident out of four observed for medication administration. On the morning of July 2, 2024, an LPN was observed administering medications to a resident, including gabapentin, which was scheduled to be given three times daily at specific times. However, the administration was delayed, and the LPN acknowledged that the delay would affect the timing of subsequent doses. The facility's policy, dated August 2023, mandates that medications be administered in a safe and timely manner, which was not adhered to in this instance.
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What surveyors actually found near you
We read the 517 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Trotwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trotwood Health & Rehab Llc | 1.3 mi | ★★★★★ | 11 | 1 |
| Arc At Trotwood Llc | 1.7 mi | ★★★★★ | 15 | 0 |
| Maria Joseph Living Care Center | 1.7 mi | ★★★★★ | 2 | 0 |
| Grace Brethren Village | 2.9 mi | ★★★★★ | 1 | 0 |
| Siena Woods Care Center | 3.5 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.