Inspection visit
Health inspection
13 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 13 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review, review of facility Self-Reported Incident (SRI), review of daily staffing
sheet, review of time clock records, resident interview, staff interview, and review of the facility policy the
facility failed to ensure residents were protected during abuse investigations. This affected one (Resident
#14) of one reviewed for abuse. The facility census was 78.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #14 revealed an admission date of 01/31/24 with diagnoses
including acute and respiratory failure with hypercapnia, congestive heart failure (CHF), bipolar disorder,
chronic kidney disease stage three, and type two diabetes mellitus.
Review of the Minimum Data Set (MDS) assessment for Resident #14 dated 02/05/24 revealed the resident
had intact cognition, required setup with eating, and was dependent on staff assistance with toileting,
bathing, dressing, and transfers.
Review of the Self-Reported Incident (SRI) #245840 for Resident #14 dated 04/01/24 timed at 2:11 P.M.
revealed the resident alleged that on 03/11/24 State Tested Aide (STNA) #361 and STNA #432 raised her
too high in the stand lift after requesting them to stop. Resident #14 alleged she then passed out from the
pain and fell to the ground. STNA #361 and STNA #432 stated Resident #14 let go of the stand lift and slid
out and onto the floor. STNA #361 and STNA #432 notified Registered Nurse (RN) #393 of the incident
immediately. RN #393 assessed Resident #14 with no injuries noted besides complaint of pain to
shoulders. RN #393, STNA #361, and STNA #432 assisted Resident #14 back into bed using the Hoyer lift.
Further review of the SRI revealed the Alleged Perpetrators (APs), STNAs #361 and #432 were suspended
during the abuse investigation.
Review of the daily staffing sheet for 04/01/24 revealed STNA #361 and STNA #432 were working on the
floor.
Review of the time sheet for STNA #361 dated 04/01/24 revealed the employee did not clock out until 5:00
P.M. which was almost three hours after the SRI was initiated.
Review of the time sheet for STNA #432 dated 04/01/24 revealed the employee did not clock out until 4:44
P.M. which was two and a half hours after the SRI was initiated.
Interview on 04/01/24 at 12:55 P.M. with Resident #14 confirmed the resident made an allegtation of abuse
which occurred on 03/11/24 per STNAs #361 and STNA #432 who were assisting her with a transfer in the
stand lift. Resident #14 confirmed she asked the aides to stop lifting her because she was in pain, but they
intentionally ignored her request to stop lifting her. Resident #14 confirmed she
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 19
Event ID:
365603
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365603
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at West Park
2950 West Park Drive
Cincinnati, OH 45238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
was in so much pain she passed out and woke up on the floor.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 04/03/24 at 12:31 P.M. with the Administrator confirmed the Surveyor notified him on 04/01/24
at approximately 1:15 P.M. that Resident #14 had made an allegation of physical abuse per STNAs #361
and #432 which allegedly occurred on 03/11/24. The Administrator confirmed he initiated the SRI for abuse
for Resident #14 on 04/01/24 at 2:11 P.M. but he did not suspend STNAs #361 and #432 immediately. The
Administrator confirmed STNA #361 was permitted to work until 5:00 P.M. on 04/01/24 and STNA #432 was
permitted to work until 4:44 P.M. on 04/01/24.
Residents Affected - Few
Review of the facility policy titled Abuse dated 07/20/23 revealed the facility would ensure residents were
protected during the investigation of allegations of abuse. Facility employees who had been accused of or
suspected of resident abuse would be suspended immediately.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365603
If continuation sheet
Page 2 of 19
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365603
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at West Park
2950 West Park Drive
Cincinnati, OH 45238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Based on medical record review, staff interview, review of the facility policy, the facility failed to conduct care
conferences as required. This affected four (Residents #16, #19, #23, and #41) of five residents reviewed
for care planning. The facility census was 78.
Findings include:
1. Review of the medical record for Resident #16 revealed an admission date of 10/25/23 with diagnoses
including necrotizing fasciitis, generalized anxiety disorder, type two diabetes mellitus, peripheral vascular
disease, anemia, lumbar spina bifida without hydrocephalus, atrial fibrillation, depression, and arthropathy.
Review of the quarterly Minimum Data Set (MDS) assessment for Resident #16 dated 02/26/24 revealed
the resident had intact cognition, required setup assistance for eating, moderate assistance for oral
hygiene, and maximal assistance for toileting, bathing, dressing, personal hygiene, bed mobility and
transfer.
Review of the social services progress note for Resident #16 dated 10/27/23 revealed the facility held a
care conference with Resident #16. Further review of the social services progress notes revealed no further
documentation related to care conferences.
Interview on 04/09/24 at 12:37 P.M. with Social Services Director (SSD) #383 confirmed the facility had not
had a care conference for Resident #16 since the one on10/27/23.2. Review of the medical record for
Resident #23 revealed an admission date of 09/29/21 with diagnoses including congestive heart failure
(CHF), type two diabetes mellitus (DM II), acute and chronic respiratory failure, Alzheimer's disease,
anxiety disorder, and major depressive disorder.
Review of the MDS assessment for Resident #23 dated 03/11/24 revealed the resident had severe
cognitive impairment and required setup with eating, toileting, and bathing, and supervision with dressing
and transfers.
Review of the progress note for Resident #23 dated 08/08/23 revealed the resident was scheduled for a
care conference on 08/14/23.
Review of the medical record for Resident #23 revealed the only recent care conference completed for the
resident was held 08/14/23.
Interview on 04/03/24 at 3:24 P.M. SSD #383 confirmed the facility had not had a care conference for
Resident #23 since the one on 08/14/23. 3. Review of the medical record for Resident #19 revealed an
admission date of 06/29/18 with diagnoses including unspecified dementia without behavioral disturbance,
aphasia following cerebral infarction, abnormalities of gait and mobility, and other problems related to life
management difficulty.
Review of the MDS assessment for Resident #19 dated 01/08/24 revealed the resident had severely
impaired cognition and required extensive assistance for bed mobility, transfers, locomotion, dressing,
toileting, and personal hygiene.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365603
If continuation sheet
Page 3 of 19
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365603
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at West Park
2950 West Park Drive
Cincinnati, OH 45238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Review of care conference documentation for Resident #19 revealed no care plan conferences were
conducted for the second and third quarters of 2023 or for the first quarter of 2024. Resident #19 had a
care conference on 10/02/23.
Review of the census revealed resident #19 was in the facility continuously from 04/01/23 to 04/01/24.
Residents Affected - Some
Interview on 04/05/24 at 10:21 A.M. Resident #19's representative confirmed the facility did not conduct
care plan conferences for the second and third quarters of 2023 (April to September) or for the first quarter
of 2024 (January to March).
4. Review of the medical record for Resident #41 revealed an admission date of 11/01/23 with diagnoses
including cerebral infarction, left sided hemiparesis, diabetes mellitus type two, chronic kidney disease,
obstructive and reflux uropathy, and long-term use of anticoagulants.
Review of the MDS assessment for Resident #41 dated 02/04/24 revealed the resident had intact cognition
and required staff assistance with ADLs.
Review of care conference documentation for Resident #41 revealed no care conference was conducted in
the first quarter of 2024. A care conference was documented on 11/03/23.
Review of the census for resident #41 revealed resident #41 was in the facility continuously during the
period of 01/01/24 to 04/01/24.
Interview on 04/03/24 at 3:43 P.M. with Resident #41 confirmed the facility had not conducted a care
conference with her in the first quarter of 2024 (January to March).
Interview on 04/03/24 at 3:25 P.M. with SW #383 confirmed the facility should be conducting care plan
conferences with the resident and/or resident representative on a quarterly basis. SW #383 confirmed
facility did not have quarterly care plan conferences with the representative for Resident #19 for the second
and third quarters of 2023 and the first quarter of 2024, and confirmed the facility failed to conduct a
quarterly care conference with Resident #41 during the first quarter of 2024.
Review of the facility policy titled Care Planning - Interdisciplinary Team revised August 2022 revealed the
resident and/or resident's representative were encouraged to participate in the development of and
revisions to the resident's care plan. Care plan meetings were to be scheduled at the best time of the day
for the resident and family.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365603
If continuation sheet
Page 4 of 19
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365603
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at West Park
2950 West Park Drive
Cincinnati, OH 45238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0678
Level of Harm - Immediate
jeopardy to resident health or
safety
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to
physician orders and the resident’s advance directives.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE
FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS
SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY
Residents Affected - Few
Based on medical record review, staff interview, Physician Assistant (PA) interview, review of facility witness
statements, review of facility policy and review of the American Heart Association (AHA) guidelines, the
facility failed to ensure cardiopulmonary resuscitation (CPR) was provided to a resident who was a full
code. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or death
when Resident #76, who was a full code, was found unresponsive and without vital signs on [DATE] at 7:20
A.M. and staff failed to immediately perform CPR and the resident was subsequently pronounced dead.
This affected one (Resident #76) of three residents reviewed for death over the last three months. The
facility census was 78.
On [DATE] at 1:25 P.M., the Administrator, Regional Director of Clinical Operations (RDCO) #508, the
Director of Nursing (DON), and Director of Operations (DO) #517 were notified of the Immediate Jeopardy,
which began on [DATE] at approximately 7:20 A.M. when the facility failed to initiate CPR for Resident #76
who was a full code and was found unresponsive and without vital signs. Registered Nurse (RN) #393 was
completing morning rounds on [DATE] at 7:20 A.M. when she found Resident #76 unresponsive and absent
of all vital signs. RN #393 then called for help and left the room to summon assistance from PA #500. RN
#385 called nine-one-one (911). The facility staff did not initiate CPR for Resident #76.
The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective
actions:
On [DATE], Resident #76 expired in the facility and was transferred to the funeral home.
On [DATE], the facility obtained written statements from staff involved in the incident with Resident #76 on
the following dates and times: on [DATE] at 7:45 A.M. from Licensed Practical Nurse (LPN) #406, on [DATE]
at 8:00 A.M. from RN #385, on [DATE] at 8:15 A.M. from State Tested Nursing Assistant (STNA) #432, on
[DATE] at 2:50 P.M. from RN #393, on [DATE] at 5:26 P.M. from LPN #341, on [DATE] at 5:54 P.M. from LPN
#507, and on [DATE] at 9:00 A.M. from STNA #337.
On [DATE] at 2:00 P.M., [NAME] President of Clinical Operations (VPCO) #510 reviewed the facility policies
titled Advanced Directives, Change-in-Condition, and Emergency Procedure-Cardiopulmonary
Resuscitation and made no changes or revisions.
On [DATE] starting at 2:45 P.M. to 7:10 P.M., RDCO #508 educated the Administrator and the DON on the
facility policies titled Emergency Procedure-Cardiopulmonary Resuscitation and Change in a
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365603
If continuation sheet
Page 5 of 19
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365603
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at West Park
2950 West Park Drive
Cincinnati, OH 45238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0678
Resident's Condition or Status. The Administrator and DON educated the management team on the
policies. The management team then educated all staff in all departments, on the policies.
Level of Harm - Immediate
jeopardy to resident health or
safety
-
Residents Affected - Few
On [DATE] through [DATE] Agency staff was educated on facility policies titled Emergency
Procedure-Cardiopulmonary Resuscitation and Change in a Resident's Condition or Status by the facility
management team.
On [DATE] at 9:30 A.M., the Administrator, the DON, Assistant Director of Nursing (ADON) #392, and LPN
#406 started audits five times a week for four weeks to ensure the residents' code status was honored. No
additional codes occurred during this time period. The audits were completed on [DATE].
On [DATE] at 3:00 P.M., the Administrator and the DON educated PA #500 on the facility policies titled
Emergency Procedure-Cardiopulmonary Resuscitation and Change in a Resident's Condition or Status.
On [DATE] at 4:27 P.M., the facility held an ad-hoc Quality Assurance Performance Improvement (QAPI)
committee meeting to discuss the root-cause of why CPR was not provided to Resident #76 who was a full
code status, and to discuss the steps that were necessary to show performance improvement moving
forward. The attendees were as follows: the Administrator, the DON, ADON #392, LPN #374, LPN #406,
Social Worker (SW) #383, SW #324, LPN #315, Activities Director (AD) #304, Maintenance Director (MD)
#307, Human Resources Manager (HRM) #316, Staffing Coordinator (SC) #421, and Medical Director
#512 via phone. The committee discussed the results of the interviews with the staff working the night prior
to the incident with Resident #76 and with the staff working at the time of the incident and determined the
resident had not experienced an obvious change in condition prior to the incident. The committee discussed
VPCO #510's review of the facility policies titled Advanced Directives, Change-in-Condition, and
Emergency Procedure-Cardiopulmonary Resuscitation, and made no changes to the policies. The
committee discussed and assigned audits to the nursing management on ensuring residents' code status
was honored and they were to be completed over a four-week period, for four weeks.
- On [DATE], [DATE], and [DATE] nursing management completed a mock Code Blue Drill with follow up
evaluation completed.
Interviews on [DATE] between 11:45 A.M. and 12:10 P.M. with STNAs #349, #355, #367, #381, and #448,
LPNs #305, #315, #416, #418, and RN #393 confirmed they had received education regarding CPR and
change in condition.
Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at a Severity Level 2
(no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until the
deficient practice was corrected on [DATE] when the facility implemented the above corrective
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365603
If continuation sheet
Page 6 of 19
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365603
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at West Park
2950 West Park Drive
Cincinnati, OH 45238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0678
actions.
Level of Harm - Immediate
jeopardy to resident health or
safety
Findings include:
Residents Affected - Few
Review of the closed medical record of Resident #76 revealed an admission date of [DATE]. The resident
died in the facility on [DATE]. Diagnoses included left hip fracture, essential hypertension, paralytic ileus,
pancytopenia, cachexia, chronic iron deficiency anemia secondary to blood loss, congestive heart failure,
adult failure to thrive, severe protein-calorie malnutrition, atrial fibrillation, chronic thromboembolic
pulmonary hypertension, and gastro-esophageal reflux disease (GERD).
Review of the comprehensive Minimum Data Set (MDS) assessment for Resident #76 dated [DATE]
revealed the resident had severe cognitive impairment.
Review of the physician orders for Resident #76 revealed an order dated [DATE] for the resident to be a full
code.
Review of the care plan dated [DATE] revealed the resident was a full code.
Review of the nurse's progress note for Resident #76 dated [DATE] timed at 8:06 A.M. per RN #393
revealed the nurse arrived on the unit, received report, and went to assess Resident #76. The nurse called
to Resident #76, and he did not respond. Resident #76 was not breathing and did not have a pulse. PA
#500 was made aware of Resident #76's condition, 911 was called, and the crash cart was brought to the
room. Resident #76 was pronounced expired at 7:20 A.M.
Review of the nurse's progress note for Resident #76 dated [DATE] timed at 8:59 A.M. per LPN #404
revealed the nurse arrived on the unit and staff nurses and PA #500 were in Resident #76's room. Resident
#76 was absent of breath sounds and had no pulse. 911 had been called and the crash cart was in
Resident #76's room. Resident #76's skin was noted to be cold. 911 arrived, hooked the resident to the
monitor and had no results. Time of death was called at 7:20 A.M.
Review of the progress note for Resident #76 per PA #500 dated [DATE] timed at 3:56 P.M. revealed on
[DATE] PA #500 was asked to examine Resident #76 because the resident was not responding. Upon
examination, Resident #76 was not responding to verbal or tactile stimuli, was not breathing, and did not
have a pulse. 911 was called and the crash cart was obtained. Emergency Medical Services (EMS) arrived,
assessed the resident, determined the resident had expired, and EMS left the building.
Review of the death certificate for Resident #76 dated [DATE] revealed the cause of the resident's death on
[DATE] was determined to be acute respiratory failure with underlying hypoxia.
Interview on [DATE] at 11:51 A.M. with RN #393 confirmed she was Resident #76's nurse on the morning
he was found not responding, not breathing, and without a pulse. RN #393 confirmed Resident #76 was a
full code. RN #393 confirmed CPR was not initiated for the resident. RN #393 stated she asked PA #500 to
assess the resident and the PA stated the resident had already died.
Interview on [DATE] at 10:22 A.M. with LPN #406 confirmed on the morning of [DATE], she arrived on the
unit between 7:15 A.M. and 7:30 A.M. and was alerted there was something going on in Resident #76's
room. LPN #406 confirmed as she was walking to Resident #76's room, RN #393 and PA #500 were
coming out of Resident #76's room and she heard PA #500 state the resident was gone. LPN #406 stated
CPR was not initiated because it was obvious he was gone.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365603
If continuation sheet
Page 7 of 19
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365603
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at West Park
2950 West Park Drive
Cincinnati, OH 45238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0678
Level of Harm - Immediate
jeopardy to resident health or
safety
A follow-up telephone interview on [DATE] at 10:36 A.M. with RN #393 confirmed upon finding Resident
#76 without vital signs on [DATE] she asked PA #500 to come to Resident #76's room to assess the
resident. RN #393 stated PA #500 assessed the resident, pronounced the resident's death, and advised RN
#393 not to do CPR. RN #393 stated she had directed the staff to call 911 before PA #500 entered
Resident #76's room. RN #393 stated she was unsure how long it took for EMS to arrive, but when they
arrived, they checked for a pulse and heart rate, and did not do anything further with the resident.
Residents Affected - Few
Interview on [DATE] at 11:08 A.M. with the DON confirmed if a nurse found a resident who was a full code
to be without vital signs, the nurse should immediately initiate CPR. The DON further confirmed the facility
staff failed to initiate CPR for Resident #76 who was a full code and was found without vital signs on
[DATE].
Telephone interview on [DATE] at 12:57 P.M. with PA #500 confirmed RN #393 asked him to assess
Resident #76 and the nurse told the PA the resident was a full code. PA #500 stated he went to assess
Resident #76 and told RN #393 to run the code and call 911. PA #500 stated he did not pronounce
Resident #76's death. PA #500 stated he then left the room as he felt the situation was under control with
the nurses, though he did not witness anybody start CPR on Resident #76. PA #500 confirmed he stopped
coming to the facility around [DATE] because the facility had a nurse practitioner who began coming to the
facility three times per week.
Review of a written statement dated [DATE] per LPN #406 revealed upon arriving on the unit, she was
informed Resident #76 had coded. As LPN #406 was on her way to Resident #76's room, PA #500 and
nurses were coming out of the room. One nurse was on the phone giving 911 information, and PA #500
stated Resident #76 was gone but he was a full code. Another nurse stated he was cold. LPN #406 asked
another nurse to get the crash cart. As the crash cart was being brought up the hall, paramedics arrived on
the unit. LPN #406 told the paramedics that PA #500 had stated Resident #76 was deceased , but the
resident was a full code. Paramedics went to the room and hooked the resident up to a monitor. After a
minute or two, the paramedics removed the monitor and asked what time the nurse found him. The nurse
stated 7:20 A.M. The paramedic stated the time of death was 7:20 A.M., and the paramedics left.
Review of the facility policy titled Advanced Directives dated [DATE] revealed advanced directives would be
respected in accordance with state law and facility policy.
Review of the facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation dated [DATE]
revealed if a resident was found unresponsive and not breathing normally, a licensed staff member who
was certified in CPR/BLS (basic life support) shall initiate CPR.
Review of the American Heart Association (AHA) guidelines dated [DATE] revealed the AHA urged all
potential rescuers to immediately start CPR unless a valid DNR order was in place or there were obvious
clinical signs of irreversible death present (e.g. rigor mortis, dependent lividity, decapitation, transection, or
decomposition) or initiating CPR could cause injury or peril to the rescuer.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365603
If continuation sheet
Page 8 of 19
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365603
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at West Park
2950 West Park Drive
Cincinnati, OH 45238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on record review, observation, staff interview, and review of the facility policy, the facility failed to
properly transfer the resident using an appropriate assistive lift device. This affected one (Resident #14)
resident of two residents reviewed for falls. The facility census was 78.
Findings include:
Review of the medical record for Resident #14 revealed an admission date of 01/31/24 with diagnoses
including acute and respiratory failure with hypercapnia, congestive heart failure (CHF), bipolar disorder,
chronic kidney disease stage three, and type two diabetes mellitus (DM II).
Review of the care plan for Resident #14 dated 02/01/24 revealed the resident was at risk for falls related to
DM II and CHF. Interventions included the following: call light and personal items within reach while in room,
staff to ensure a clutter-free environment and adequate lighting, staff to observe for safety, staff to provide
rest periods, staff to use proper assistive devices.
Review of the Minimum Data Set (MDS) assessment for Resident #14 dated 02/05/24 revealed the resident
had intact cognition, required setup with eating, and was dependent on staff with toileting, bathing,
dressing, and transfers.
Review of the progress note for Resident #14 dated 03/11/24 timed at 6:33 P.M. revealed the resident slid
out of sit-to-stand lift while two staff transferred the resident to the bed and the resident landed on the floor.
The nurse assessed Resident #14 for injuries and found none. Staff assisted the resident into bed using a
Hoyer lift.
Review of the progress note for Resident #14 dated 03/13/24 timed at 12:57 P.M. revealed the
interdisciplinary team (IDT) met to discuss the resident's fall on 03/11/24. The IDT determined the resident
should be evaluated and treated by physical therapy and staff should utilize a Hoyer lift for transfers to
prevent further falls.
Review of the physical therapy note for Resident #14 dated 04/01/24 revealed staff should utilize a Hoyer lift
for all transfers in and out of bed for resident and staff safety.
Observation on 04/04/24 at 11:38 A.M. revealed State Tested Nursing Assistants (STNAs) #311 and STNA
#518 transferred Resident #14 from bed to wheelchair using the sit to stand lift.
Interview on 04/09/24 at 11:22 A.M. with Physical Therapist (PT) #314 confirmed staff should be utilizing
the Hoyer lift when transferring Resident #14.
Review of the facility policy titled Lifting Machine, Using a Mechanical Lift dated October 2022 revealed staff
would follow general principles of safe lifting using a mechanical lifting device. Before using a lift, staff
should assess the resident's condition to determine the resident's appropriateness for transfer using a
mechanical lift.
This deficiency represents noncompliance investigated under Complaint Number OH00152118.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365603
If continuation sheet
Page 9 of 19
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365603
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at West Park
2950 West Park Drive
Cincinnati, OH 45238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review, staff interview, and review of the facility policy, the facility failed to
implement nutritional recommendations made per the licensed dietitian for residents with weight loss. This
affected one (Resident #11) of three residents reviewed for nutrition. The facility census was 78.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #11 an admission date of 03/31/20 with diagnoses including
polyneuropathy, cellulitis of right lower limb, generalized anxiety disorder, major depressive disorder,
dementia, other cervical disc degeneration, and peripheral vascular disease.
Review of the plan of care dated for Resident #11 dated 01/03/24 revealed the resident was at risk for
alteration in nutrition related to polyneuropathy, depression, hypertension, cervical disc degeneration,
peripheral vascular disease, anemia, cognitive communication deficit, and anxiety. The plan of care also
indicated the resident was at risk for malnutrition due to history of weight fluctuations and advanced age.
Interventions included the following: administer medications as ordered, honor food preferences as able,
offer substitutes as needed, provide and serve diet as ordered, provide and serve supplements as ordered,
registered dietician to evaluate and make diet change recommendations as needed.
Review of the physician orders for Resident #11 revealed an order dated 01/15/24 for a house supplement
in the morning.
Review of the quarterly Minimum Data Set (MDS) assessment for Resident #11 dated 03/01/24 revealed
the resident had moderately impaired cognition and required setup assistance for eating.
Review of the weight records revealed Resident #11 weighed 122 pounds on 01/12/24, 117 pounds on
02/04/24, 113 pounds on 03/03/24, 109 pounds on 04/03/24, and 113 pounds on 04/09/24.
Review of the nutrition assessment for Resident #11 dated 03/03/24 completed per Diet Technician (DT)
#511 revealed the resident had a significant weight loss trend in the last 90 days with a recommendation to
increase the house supplement to twice a day between meals due to significant weight loss.
Review of the April 2024 physician orders for Resident #11 revealed the resident's order for house
supplement once per day dated 01/25/24 had not been updated to reflect DT #511's recommendation to
increase the house supplement to twice daily.
Interview on 04/09/24 at 5:16 P.M. with the Director of Nursing (DON) confirmed the order for a house
supplement for Resident #11 had not been increased per the recommendation of DT #511 made on
03/03/24.
Review of the facility policy titled Weight Assessment and Intervention dated August 2023 revealed the
facility staff would implement interventions for undesirable weight loss based upon resident choices and
preferences and the nutritional needs of the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365603
If continuation sheet
Page 10 of 19
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365603
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at West Park
2950 West Park Drive
Cincinnati, OH 45238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
Based on record review, staff interview, and review of the facility policy, the facility failed to implement
physician orders following pharmacy recommendations. This affected three (Residents #5, #16, and #23) of
five residents reviewed for unnecessary medications. The facility census was 78.
Findings include:
1. Review of the medical record for Resident #5 revealed an admission date of 09/12/22 with diagnoses
including cerebral infarction, schizophrenia, anxiety, expressive language disorder, depression, and
dementia.
Review of the Minimum Data Set (MDS) assessment for Resident #5 dated 01/15/24 revealed the resident
had severe cognitive deficits and required extensive to total dependence with activities of daily living
(ADLs.)
Review of pharmacy recommendation for Resident #5 dated 06/21/23 revealed a recommendation to
discontinue Seroquel 25 milligrams (mg) by mouth at bedtime signed by the medical director on 07/17/23
indicating agreement with the recommendation.
Review of the physician orders for Resident #5 revealed an order dated 11/03/23 to discontinue Seroquel
25 mg.
Interview on 04/10/24 at 12:50 PM with the Director of Nursing (DON) confirmed the pharmacist made a
recommendation on 06/21/23 to discontinue Seroquel 25 mg for Resident #5. The physician signed in
agreement of the recommendation on 07/17/23 but the recommendation was not implemented until
Seroquel 25mg was discontinued on 11/03/23.
2. Review of the medical record for Resident #23 revealed an admission date of 09/29/21 with diagnoses
including congestive heart failure (CHF), type two diabetes mellitus (DM II), acute and chronic respiratory
failure, Alzheimer's disease, anxiety disorder, and major depressive disorder.
Review of the MDS assessment for Resident #23 dated 03/11/24 revealed the resident had severe
cognitive impairment and required supervision with ADLs.
Review of the pharmacy recommendation for Resident #23 dated 07/17/23 revealed a recommendation to
increase lisinopril to 30 mg once daily. The physician signed agreement with the recommendation.
Review of the physician order for Resident #23 dated 10/03/23 revealed an order for lisinopril 30 mg every
day.
Review of the pharmacy recommendation for Resident #23 dated 02/13/24 revealed a recommendation to
increase Novolog insulin six units three times daily with meals. The physician signed agreement with the
recommendation.
Review of the physician orders for April 2024 for Resident #23 revealed there was no order for six units of
Novolog to be given three times a day with meals.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365603
If continuation sheet
Page 11 of 19
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365603
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at West Park
2950 West Park Drive
Cincinnati, OH 45238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on 04/10/24 at 10:06 A.M. with the Assistant Director of Nursing (ADON) confirmed the
pharmacist made a recommendation on 07/17/23 to increase Resident #23's lisinopril. The physician
signed agreement to increase the lisinopril, but the recommendation was not implemented until 10/03/23.
Interview with the ADON also confirmed the pharmacist made a recommendation to increase Resident
#23's Novolog insulin to six units three times per day with meals. The physician signed agreement to
increase the resident's insulin, but the facility had not implemented the recommendation.
3. Review of the medical record for Resident #16 revealed an admission date of 10/25/23 with diagnoses
including necrotizing fasciitis, generalized anxiety disorder, type two diabetes mellitus, peripheral vascular
disease, anemia, lumbar spina bifida without hydrocephalus, atrial fibrillation, depression, and arthropathy.
Review of the MDS assessment for Resident #16 dated 02/26/24 revealed the resident had intact cognition
and required staff assistance with ADLs.
Review of the pharmacy recommendation for Resident #16 dated 02/13/24 revealed a recommendation to
start a dose of Insulin Lispro at two units daily. Nurse Practitioner (NP)#514 signed agreement with the
recommendation on 02/23/24.
Review of the April 2024 physician orders for Residents #16 revealed there were no orders for insulin
Lispro two units.
Interview on 04/09/24 at 5:10 P.M. with the DON confirmed the pharmacist made a recommendation on
02/13/24 to start insulin Lispro two units which NP #514 signed in agreement on 02/23/24. Interview with
the DON confirmed the facility had not implemented the pharmacist's recommendation.
Review of the facility policy titled Medication Therapy revised April 2007 revealed shortly after admission
and periodically thereafter, the facility and practitioner with the assistance of the Consultant Pharmacist
would review a resident's medication regimen to identify whether there was a clear indication for use of the
medication, appropriate dosage, frequency of administration and duration of use are appropriate, and any
potential or suspected side effects that are present.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365603
If continuation sheet
Page 12 of 19
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365603
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at West Park
2950 West Park Drive
Cincinnati, OH 45238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review, observation, staff interview, and review of the facility policy, the facility
failed to ensure a medication error of below five percent for medication administration observation. The
medication error rate was eight percent (%.) This affected one (Resident #55) of four residents observed for
medication administration. The facility census was 78.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #55 revealed an admission date of 02/16/23 with diagnoses
including diabetes, atrial fibrillation, insomnia, hypertension, and Asperger's syndrome.
Review of the Minimum Data Set (MDS) for Resident #55 dated 02/19/24 revealed the resident was
cognitively impaired and required staff assistance with activities of daily living (ADLs).
Review of physician orders for Resident #55 revealed the resident had an orders for pantoprazole 40
milligrams in the morning and Flonase nasal spray two sprays in each nostril each morning.
Observation on 04/03/24 at 9:03 A.M. of medication administration for Resident #55 per Licensed Practical
Nurse (LPN #505) revealed the nurse administered the resident's morning medications but omitted
administration of pantoprazole and Flonase. LPN #505 signed the medications off in the electronic medical
record (EMR) as administered.
Interview on 04/03/24 at 9:27 P.M. with LPN #505 confirmed she was nervous and did not know the people
on that hall and she had signed Resident #55's pantoprazole and Flonase as administered but she had not
given the medications to the resident. LPN #505 confirmed the medication error rate for medication
administration observation was eight %.
Interview on 04/04/24 at approximately 1:00 P.M. with Regional Director of Clinical Operations (RDCO)
#508 confimred understanding that the medication error rate was eight % for the medication administration
observation completed on 04/03/24.
Review of the facility policy titled Administering Medications dated August 2022 revealed medications were
administered in safe and timely manner, and as prescribed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365603
If continuation sheet
Page 13 of 19
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365603
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at West Park
2950 West Park Drive
Cincinnati, OH 45238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on medical record review, observation, staff interviews, and review of the facility policy, the facility
failed to ensure insulin pens were properly labeled and stored. This affected two (Residents #23 and #55)
of 39 residents with medications stored in the 700 hall cart. The facility census was 78.
Findings include:
Review of the medical record for Resident #23 revealed an admission date of 09/29/21 with diagnoses
including congestive heart failure (CHF), type two diabetes mellitus (DM II), and acute kidney failure.
Review of the physician orders for Resident #23 revealed an order dated 01/17/24 for Lantus insulin inject
ten units at bedtime.
Review of the medical record for Resident #55 revealed an admission date of 02/16/23 with diagnoses
including type one diabetes mellitus, atrial fibrillation, and Asperger's syndrome.
Review of the physician orders for Resident #55 revealed an order dated 01/17/24 for Lantus insulin inject
25 units and an order dated 03/29/24 for Humalog insulin inject four units.
Observation on 04/03/24 at 4:02 P.M. of medication cart on 700 hall revealed Resident #23's Lantus insulin
pen was opened without an open date. Resident #55's insulin pens, Humalog and Lantus, were opened
without an open date.
Interview on 04/03/24 at 4:04 P.M. with Licensed Practical Nurse (LPN) #502 confirmed insulin pens should
be dated upon opening so staff would know when to discard them. LPN #502 further confirmed the insulin
pens for Resident #23 and #55 were opened but undated.
Review of the facility policy titled Administering Medications dated August 2022 revealed medications were
administered in a safe and timely manner, and as prescribed. The expiration/beyond use date on the
medication label was checked prior to administering. When opening a multi-dose container, the date
opened was recorded on the container.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365603
If continuation sheet
Page 14 of 19
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365603
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at West Park
2950 West Park Drive
Cincinnati, OH 45238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0800
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional
and special dietary needs.
Based on staff interview, observation, record review, and review of the facility policy, the facility failed to
ensure all food temperatures were checked prior to the start of meal service. This had the potential to affect
all 78 residents in the facility.
Findings include:
Interview on 04/03/24 at 4:00 P.M. with Dietary [NAME] (DC) #430 confirmed he only gets the temperature
of one food on the steam table at the beginning of each meal because if one was hot, the rest will be hot.
DC #430 further confirmed he would be testing the temperature of the chicken for the meal because it was
the only food on the steam table which did not have foil over it in addition to the metal lid. DC #430 then
tested the temperature of the chicken and the thermometer read 140 degrees Fahrenheit (F). DC #430
confirmed the chicken needed to be at least 165 degrees F and then placed the chicken back in the
steamer.
Observation on 04/03/24 at 4:10 P.M. revealed DC #430 retrieved the pan of chicken from the steamer and
placed it in the steam table. DC #430 obtained the temperature of the chicken at 179 degrees F. DC #430
then began plating food for the dinner meal. DC #430 did not obtain the temperature of any other foods.
Review of the food temperature log on 04/03/24 at 4:20 P.M. revealed there was an entry made on 04/03/24
for the chicken at 179.3 degrees F with DC #430's initials. There were no other food temperatures
documented for the date and the previous and most recent temperatures were dated 03/15/24.
Interview on 04/03/24 at 4:20 P.M. with DC #430 confirmed there were no other temperature log entries for
the dinner meal on 04/03/24
Interview on 04/09/24 at 3:16 P.M. with Registered Dietetic Technician (DTR) #511 confirmed the
temperature of all foods should be checked prior to the start of meal service.
Review of the facility policy titled Food Temperatures undated revealed all hot food items must be held and
served at a temperature of at least 135 degrees F and temperatures should be taken often to monitor for
safe food holding temperatures above 135 degrees F for hot foods.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365603
If continuation sheet
Page 15 of 19
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365603
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at West Park
2950 West Park Drive
Cincinnati, OH 45238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, staff interview, and review of facility recipes, the facility failed to properly prepare
pureed food. This had the potential to affect five (Residents #12, #22, #47, #49, #50) of five facility-identified
residents who received a pureed diet. The facility census was 78.
Residents Affected - Some
Findings include:
Observation on 04/03/24 at 1:08 P.M. revealed Dietary [NAME] (DC) #430 began process of making pureed
broccoli. DC #430 placed 6 scoops (3 cups) of broccoli into the blender pitcher and then placed the pitcher
under the water spigot and filled the pitcher to the 6-cup line. Continued observation revealed DC #430
blended the broccoli mixture in the blender for approximately four minutes. DC #430 then poured the
contents into a pan, covered the pan, and placed it in the steamer. The contents of the pitcher were liquified
and runny.
Interview on 04/03/24 at 1:10 P.M. with DC #430 confirmed he used equal parts of water and vegetables
because he wanted to make sure the food was as watery as possible to ensure the residents could digest it
without choking. DC #430 confirmed the mixture was runny and stated that's the way he wanted it to be
mixed.
Interview on 04/09/24 at 3:16 P.M. with Registered Dietetic Technician (DTR) #511 confirmed a ratio of one
part vegetable to one part water would be too much water to maintain the nutritive value of the food.
Review of the facility recipe for pureed vegetables revealed 1/4 cup of vegetables should be mixed with two
teaspoons of water and 1/4 slice of bread and blended to a mashed potato consistency.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365603
If continuation sheet
Page 16 of 19
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365603
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at West Park
2950 West Park Drive
Cincinnati, OH 45238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, staff interview, and review of the facility policy, the facility failed to ensure kitchen
equipment was maintained in a sanitary manner. The facility also failed to ensure staff wore hair restraints
which fully contained the hair while preparing food. This had the potential to affect all 78 residents in the
facility.
Findings include:
1. Observation on 04/01/24 at 8:37 A.M. revealed the hood in the kitchen, which covered the fryer, stove,
grill, and steamers, was covered with a black and grey fuzzy substance. Further observation revealed a
sticker on the hood, which indicated the last cleaning was completed on June 2023.
Interview on 04/01/24 at 8:37 A.M. with Food Service Manager (FSM) #503 confirmed the slats of the hood
in the kitchen were in need of cleaning. FSM #503 confirmed the cleaning was past due, and the hood
should be cleaned every three months.
Review of the facility policy titled Cleaning Instructions: Hoods and Filters undated revealed stove hoods
and filters should be cleaned at least monthly and professionally cleaned at least yearly.
2. Observation on 04/03/24 at 11:50 A.M. revealed Dietary [NAME] (DC) #430 was preparing food in the
kitchen. DC #430 had a beard and did not have any type of covering over the facial hair.
Interview on 04/03/24 at 11:50 A.M. with DC #430 confirmed he was not wearing anything to contain his
facial hair.
3. Observation on 04/03/24 at 11:51 A.M. revealed DC #445 was assisting with food preparation. DC #445
had facial hair which was not covered.
Interview on 04/03/24 at 11:51 A.M. with DC #445 confirmed he was not wearing anything to contain his
facial hair while preparing food.
Observation on 04/03/24 at 11:53 A.M. revealed DC #445 brought facial hair covers into the kitchen. DC
#445 applied a beard net to his face, but it was tucked under his chin and did fully contain his facial hair.
4. Observation on 04/03/24 at 11:52 A.M., revealed Dietary Aide (DA) #338 was assisting with meal service
and food preparation. DA #338 had facial hair and did not have any type of facial hair restraint.
Interview on 04/03/24 at 11:52 A.M. with DA #338 confirmed he had facial hair and was not wearing a facial
hair restraint while preparing food.
Review of the facility policy titled Employee Sanitary Practices undated revealed all employees shall wear
hair restraints to prevent hair from contacting exposed food.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365603
If continuation sheet
Page 17 of 19
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365603
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at West Park
2950 West Park Drive
Cincinnati, OH 45238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, staff interview, and review of the facility policy, the facility failed to properly
implement the Legionella plan. This had the potential to affect all of the residents residing in the facility. The
facility census was 78.
Residents Affected - Many
Findings include:
Review of the facility's water management records revealed the facility failed to complete water
temperatures for the year of 2023 which was one of the specific control measures the facility was using to
monitor Legionella.
Review of the facility temperature log revealed water temperatures had only been completed from January
2024 through March 2024. There were no water temperatures recorded for 2023.
Interview on 04/10/24 at 1:03 P.M. with Maintenance Director (MD) #307 confirmed the facility had not
completed water temperatures for the year 2023.
Review of the facility policy titled Legionella Water Management Program dated July 2017 revealed the
facility was committed to the prevention, detection, and control of water-borne contaminants, including
Legionella. The purpose of the water management program was to identify areas in the water system where
legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. Specific
measures used to control the introduction and/or spread of legionella included taking water temperatures
and use of disinfectants.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365603
If continuation sheet
Page 18 of 19
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365603
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aventura at West Park
2950 West Park Drive
Cincinnati, OH 45238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, staff interview, and review of the facility policy, the facility failed to provide the
pneumococcal vaccine in a timely manner. This affected three (Residents #10, #11, and #21) of five
resident reviewed for vaccinations. The facility census was 78.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #10 revealed an admission date of 10/22/19 with diagnoses
including type two diabetes mellitus, generalized anxiety, depression, and chronic kidney disease stage
three.
Review of the medical record for Resident #10 revealed Pneumococcal vaccine 23 (PPSV23) was given on
02/01/13. Resident #10 should have received PCV15 or PCV20 at least one year after PPSV23.
Review of the medical record for Resident #11 revealed an admission date 03/31/20 with diagnoses
including generalized anxiety disorder, major depressive disorder, and dementia.
Review of the medical record for Resident #11 revealed the PPSV23 was given on 07/01/18. Resident #11
should have received PCV15 or PCV20 at least one year after PPSV23.
Review of the medical record for Resident #21 revealed an admission date of 01/03/23 with diagnoses
including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type two
diabetes mellitus (DM II), and depression.
Review of the medical record for Resident #21 revealed the resident was not offered the pneumococcal
vaccine since admission to the facility.
Interview on 04/10/24 at 9:27 A.M. with Assistant Director of Nursing (ADON) confirmed Residents #10,
#11, and #21 were not up to date on their pneumococcal vaccines.
Review of the facility policy titled Pneumococcal Vaccine dated November 2023 revealed all residents were
offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon
admission, residents were assessed for eligibility to receive the pneumococcal vaccine series, and when
indicated, were offered the vaccine series within thirty days of admission to the facility unless medically
contraindicated or the resident had already been vaccinated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365603
If continuation sheet
Page 19 of 19
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Back to topCitations
13 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F678 - Personnel provide basic life support, including CPR, to a resident
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F800 - Food and nutrition services
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
FAQ · About this visit
Common questions about this visit
What happened during the April 17, 2024 survey of AVENTURA AT WEST PARK?
This was a inspection survey of AVENTURA AT WEST PARK on April 17, 2024. The surveyor cited 13 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AVENTURA AT WEST PARK on April 17, 2024?
Yes, 13 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a t..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.