Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 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 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.
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.
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.
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 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.
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 368 citations issued within 25 miles in the last 12 months — including the 1 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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Illustrative
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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 | — | 9 | 1 |
| Arc At Trotwood Llc | 1.7 mi | — | 7 | 0 |
| Maria Joseph Living Care Center | 1.7 mi | — | 2 | 0 |
| Grace Brethren Village | 2.9 mi | — | 0 | 0 |
| Siena Woods Care Center | 3.5 mi | — | 6 | 0 |
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