Inspection·July 15, 2021

F 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete safeguard, manage, and account for personal funds of the resident deposited with the facility. General categories of items and services that the facility may charge to the residents' fund if they are requested by the resident, if the facility informs the resident that there will be a charge, and if payment is not made by Medicaid: are telephone, television, personal comfort items, cosmetics and grooming items in excess of those for which the payment is made under Medicaid, personal clothing, gifts purchased on the behalf of the resident, personal reading material, social events and entertainments offered outside the scope of activities programs, private rooms (except when therapeutically required), and specially prepared or alternative food requested instead of the food generally prepared by the facility. Event ID: Facility ID: 365917 If continuation sheet Page 2 of 11 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 Villa Road Springfield, OH 45503 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview, the facility failed to notify the resident/resident representative of the bed hold and reserve bed payment policy upon the resident's transfer to the hospital. This affected one (#79) of two residents reviewed for hospitalization. The facility census was 80. Findings include: Review of the medical record for Resident #79 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic bronchitis, and irritable bowel syndrome. Review of the five-day Minimum Data Set (MDS) assessment, dated 05/02/21, revealed Resident #79 had intact cognition. Review of a progress note, dated 05/02/21 at 8:50 A.M., revealed Resident #79's oxygen saturation was 60. The resident had diminished lung sounds with wheezing and was using accessory muscles to breath. The resident complained of nausea. Four liters of oxygen was administered to the resident and the resident's oxygen saturation increased to 86. The physician was notified of the resident's change of condition and an order was given to send the resident to the hospital for evaluation and treatment. The resident was noted to be admitted to the hospital. Review of the medical record for Resident #79 revealed there was no evidence of the resident or representative being notified of the facility's bed hold policy. Interview on 07/15/21 at 10:35 A.M. with the Director of Nursing (DON) verified Resident #79 or the resident's representative were not provided information related to the facilities bed hold notice and reserve payment policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 3 of 11 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 Villa Road Springfield, OH 45503 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 - Few 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, resident and family interview, staff interview, and policy review, the facility failed to have quarterly care conferences and include the resident and the resident's representatives to participate in care planning. This affected one (#5) of one resident reviewed for care planning. This had the potential to affect all 80 residents residing in the facility. Findings include: Review of the medical record of Resident #5 revealed an admission date of 03/23/19. Diagnoses included unspecified cord compression, chronic obstructive pulmonary disease, muscle weakness, unspecified edema, pharyngeal phase dysphagia, hypotension, hyperlipidemia, hypothyroidism, gastro-esophageal reflux disease, anxiety disorder, major depressive disorder, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/18/21, revealed the resident had intact cognition. Review of the progress notes, dated 01/01/20 through 07/14/21, revealed care conferences were held on 01/23/20, 07/02/20, and 10/19/20. There was no evidence of any further communication regarding care conferences. Interview on 07/12/21 at 4:53 P.M. with Resident #5 and Resident #5's representative stated it had been awhile since the facility had offered to do a formal care conference. Resident #5 further stated there was a new person in social services and did not think care conferences were being scheduled yet. Interview on 07/14/21 at 8:18 A.M. with Licensed Social Worker (LSW) #27 stated care conferences were to be held at least quarterly. Subsequent interview on 07/14/21 at 1:05 P.M. with LSW #27 verified there was no evidence of a care conference being held since 10/19/20 for Resident #5. LSW #27 further verified there was no evidence of any communication with the resident or family refusing a care conference since 10/19/20. LSW #27 stated she was unsure why a care conference had not been held for Resident #5 since 10/19/20. Review of the facility's policy titled Resident Participation-Assessment/Care Plans, last revised 12/2016, revealed residents and their representatives are encouraged to attend and participate in the development of the resident's person-centered care plan and the resident and resident's representative has the right to participate in the planning process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 4 of 11 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 Villa Road Springfield, OH 45503 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 medical record review, staff interview, and policy review, the facility failed to ensure the physician documented rationale for disagreeing with the pharmacy recommendations. This affected two (#12 and #47) of five residents reviewed for unnecessary medications. The facility census was 80. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 05/20/20. Diagnoses included gastroesophageal reflux disease (GERD) and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/21, revealed the resident had intact cognition. Review of the physician orders, dated 06/21/21, revealed an order for Reglan (anti-vomiting agent) 10 milligrams (mg.) by mouth four times per day. The orders were not changed as of 07/14/21. Review of the Consultant Pharmacist admission Review, dated 06/22/21, revealed a pharmacologic concern regarding the resident receiving Metocloprimide (Reglan) 10 mg. four times daily for GERD. Further instructions were documented Metocloprimide can cause extrapyramidal effects. May wish to re-evaluate Metocloprimide use. May wish to consider alternative therapy with a proton pump inhibitor. The physician signed the form on 07/02/21. No further comments were included on the form. Review of the physician progress notes, dated 06/21/21 through 07/14/21, revealed there was no documentation regarding the pharmacy recommendations made on 06/22/21. Interview on 07/15/21 at 4:05 P.M. with Registered Nurse (RN) #28 verified there was no evidence of physician rationale for disagreeing with the pharmacy recommendations for Resident #12 made on 06/22/21. The RN verified there were no changes made to Reglan after the pharmacy recommendation on 06/22/21. 2. Review of the medical record for Resident #47 revealed an admission date of 04/05/21. Diagnoses included gastroparesis, essential hypertension, and anxiety disorder. Review of the Medicare five-day MDS assessment, dated 05/21/21, revealed the resident had impaired cognition. Review of the physician orders, dated 05/14/21, revealed an orders for Metocloprimide five mg. by mouth before meals and at bedtime and Protonix 40 mg. by mouth one time a day. The orders were not changed as of 07/14/21. Review of the Consultant Pharmacist admission Review, dated 05/18/21, revealed a pharmacologic concern regarding the resident receiving triple therapy with Metocloprimide (Reglan) five mg. before meals and at bedtime and Pantoprazole (Protonix) 40 mg. daily for GERD. Further instructions read to review to ensure concomitant therapy with both was indeed needed. The suggestion was discontinuing Metocloprimide therapy as it can cause extrapyramidal effects, including tardive dyskinesia (risk was greater in frail old adults) and was dosed four times a day. The form was signed by the physician on 06/18/21. No further comments were included on the form. Review of the physician progress notes, dated 05/14/21 through 07/14/21, revealed no documentation regarding the pharmacy recommendations made on 05/18/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 5 of 11 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 Villa Road Springfield, OH 45503 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 07/15/21 at 4:05 P.M. with RN #28 verified there was no evidence of physician rationale for disagreeing with the pharmacy recommendations for Resident #47 made on 05/18/21. The RN verified there were no medication changes related to Reglan and Protonix since the pharmacy recommendation was made on 05/18/21. Review of the facility's policy titled Medication Regimen Review, updated 03/2009, revealed pharmacy recommendations must be addressed and appropriate action taken in a reasonable amount of time. Review of the facility's undated policy titled Medication Regimen Review Form Completion revealed the if the physician did not write new orders, a brief explanation should be noted on the form to justify the declined recommendation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 6 of 11 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 Villa Road Springfield, OH 45503 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. 2. Review of the medical record for Resident #19 revealed an admission date of 02/26/16. Diagnoses included hypothyroidism, Parkinson's Disease, dysarthria, hypertension (HTN), anxiety, major depressive disorder, and hypothyroidism. Review of the Minimum Data Set (MDS) assessment, dated 06/24/21, revealed Resident #19 had moderately impaired cognition and did not reject care. Review of the plan of care for Resident #19 revealed the resident received a diuretic daily and the resident was at risk for side effects of psychotropic medication related to use of Seroquel and Zoloft. Interventions included to monitor laboratory (labs) results as ordered. Review of the physician orders for Resident #19, dated 12/09/17, revealed the resident was ordered to have a basic metabolic panel (BMP) every three months (December, March, June, and September). Physician orders, dated 12/09/17, indicated the resident was ordered to have a complete metabolic panel (CMP), complete blood count (CBC) and thyroid stimulating hormone (TSH) every six months (December and June). During review of the electronic medical record (EMR) review for Resident #19 on 07/14/21 at 10:00 A.M. revealed the last recorded lab results were dated 06/30/20. During review of the hard/paper medical record for Resident #19 on 07/14/21 at 10:25 A.M. revealed no documented evidence of any lab results. Additional review of the hard/paper medical record revealed a June 2021 treatment administration record (TAR) which indicated the labs were completed on 06/08/21. Review of the nurse's progress notes for Resident #19 dated December 2020, March 2021 and June 2021 revealed no documented evidence the lab results were followed-up on and /or the advanced provider(s) were notified of the lab results from 12/08/20, 03/16/21 and 06/08/21. Interview with Licensed Practical Nurse (LPN) # 21 on 07/14/21 at 11:00 A.M. verified there were no posted lab results in the EMR or in the hard/paper medical chart for Resident #19. LPN #21 verified the resident was ordered to have labs completed in December 2020, March 2021, and June 2021. LPN #21 verified the TAR in the paper chart indicated labs were completed on 06/08/21 but verified there were no results posted. LPN# 21 also verified there were no lab results in the physician's book awaiting to be reviewed or in the binder of labs awaiting to be filed away. LPN #21 stated she would call the lab service to find out if any labs results were recorded. Subsequent interview with LPN #21 on 07/14/21 at 11:19 A.M. indicated she called the lab company and they faxed her lab results from 06/08/21. LPN #21 additionally stated there was no documented evidence the facility received the lab results prior to today's date. LPN #21 also verified there was documented evidence the advanced provider was notified of the lab results. Interview with Registered Nurse (RN) #20 on 07/14/21 at 11:25 A.M. verified Resident #18 was ordered to have labs of BMP every three months, and CBC, CMP and TSH every six months. RN #20 verified there were no lab results for December 2020 or March 2021. RN #20 stated LPN #21 called the lab service and received lab results for 06/08/21. Subsequent interview with RN #20 on 07/14/21 at 11:30 A.M. indicated she printed off lab results from 12/08/20 and 03/16/21. RN # 20 stated the there was no documented evidence the facility had the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 7 of 11 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 Villa Road Springfield, OH 45503 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lab results from 12/08/20, 03/16/21, and 06/08/21 prior to surveyor intervention regarding the whereabouts of the labs. RN #20 also verified there was no documented evidence the lab results were reviewed by advanced providers. Based on medical record review and staff interview, the facility failed to obtain lab work as ordered by the physician and the facility failed to ensure laboratory results were promptly reported to the advanced provider. This affected two (#19 and #47) of eight residents reviewed for laboratory orders. The facility census was 80. Findings include: 1. Review of the medical record for Resident #47 revealed an admission date of 04/05/21. Diagnoses included heart failure and atrial fibrillation. Review of the Medicare five-day Minimum Data Set (MDS) assessment, dated 05/21/21, revealed the resident had impaired cognition. Review of the physician's orders, dated 05/14/21, revealed an order for a Digoxin level (to monitor for toxicity and/or low levels of Digoxin) to be drawn on 05/18/21. Review of Resident #47's labs revealed no evidence of a Digoxin level being completed as ordered. Interview on 07/14/21 at 11:44 A.M. with the Administrator verified no Digoxin level was completed on 05/18/21 as ordered, nor had a Digoxin level been checked since the lab work was ordered on 05/14/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 8 of 11 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 Villa Road Springfield, OH 45503 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 facility record review, staff interview, review of the facility's policy, review of the online resources from the Centers for Disease Control and Prevention (CDC), and memorandums from the centers for Medicare and Medicaid services (CMS), the facility failed to implement a water treatment program that followed the American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRA) industry standards and the CDC toolkit for prevention of Legionella. This had the potential to affect all 80 resident who resided in the facility. Residents Affected - Many Findings included: During the facilities infection control log books and programs on 07/15/21 at 2:00 P.M. revealed the facility failed to implement an appropriate water treatment program to monitor and prevent the spread of Legionnaires Disease. The facility did not have any records of routine maintenance, cleaning and water treatment services. Review of the facility's policy titled Monitoring Waterborne Organisms, dated 05/19/17, revealed the facility would provide guidance for monitoring the domestic and open water systems suspected of being the source of a waterborne organisms in the water system in the healthcare facility. Under the title Risk Assessments, the facility indicated they would inventory all water systems that could be a source for waterborne infection source. The inventory list included open water systems as domestic water systems such as hot water tanks, cooling towers, water display fountains, spas, pools, fish tanks and other reservoirs located through the facility. Risk assessment also indicated each patient care system which could harbor infectious agents should be assessed and identified by the type of system, location, consequence of contamination, corrective action, and alternative supply or service available if system was shut down, the actions required to control and eliminate the potential growth of these agents as well the records of routine maintenance, cleaning and water treatment services performed should be readily available for review. Review of the facility's policy titled Legionella Surveillance and Detection, dated 07/01/17, revealed the facility was committed to the prevention, detection and control of water borne contaminants and legionaries would be part of the infection surveillance. Review of the facility's document titled Water Treatment Program, dated 2018, revealed if/when the facility had reported legionnaires disease diagnosis, the facility would call the local health district to have the facilities water sampled at different points within the building. Interview with the Administrator on 07/16/21 at 2:45 P.M. indicated the facility followed the guidance of the local health department for Legionella. The Administrator further stated the facility did not complete any water testing for Legionella within the facility due to the local health department advised the facility was not required to test the water due to the local assessment for Legionella being low. Interview with Facility Services Director (FSS) #30 on 07/16/21 at 2:50 P.M. verified the facility did not have any documented evidence the facility followed their risk assessment. FSS #30 also verified the facility did not implement a water management program that considered the ASHRAE industry standards and CDC toolkit guidelines, to include control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. The program does not include specificity regarding testing protocols and acceptable ranges for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 9 of 11 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 Villa Road Springfield, OH 45503 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many control measures, and documentation of the results of testing and corrective actions taken when control limits were not maintained. Review of the online resources from the CDC titled https://www.cdc.gov/Legionella/wmp/toolkit/wmp-risk.html, updated 03/25/21, revealed the tool kit would help the facility develop and implement a water management program to reduce the facilities risk for growing and spreading Legionella. The toolkit indicated if the facility answered yes to any of the questions one through four, they should have a water management program for the building's hot and cold-water distribution system. Question one - Is your building a healthcare facility where patients stay overnight or does your building house or treat people who have chronic and acute medical problems or weakened immune systems? Question two - Does your building primarily house people older than 65 years? Question three - Does your building have multiple housing units and a centralized hot water system? The toolkit indicated the facility should have a process of implementing and monitoring control measures (temperature levels and /or disinfectant levels) and take immediate action if control measures were not being met. The toolkit additionally laid out numerous specific guidelines for an effective water management program the facility should follow. Review of the CMS memorandum titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires Disease, dated 06/02/17, indicated the facility shall implement a water management program that considered the ASHRA industry standards and the CDC toolkit, which included control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. The memo also indicated the facility would have to specify testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained. CMS memorandum also indicated the facility was expected to comply with CMS requirements to protect the health and safety of its residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 10 of 11 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 365917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Oakwood Village 1500 Villa Road Springfield, OH 45503 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, resident and staff interview, and review of the facility's policy, the facility failed to provide a safe and comfortable environment for the residents. This affected one (#38) of 24 residents reviewed for physical environment and had the potential to affect all 80 residents who resided in the facility. Findings included: 1. During an observation of the laundry area on 07/15/21 at 9:25 A.M. revealed the facility had three natural gas dryers in operation. Further observation revealed dryer #1 (far left) was on and the burner assembly compartment had excessive amount of dryer lint in the compartment. Further observation of dryers #2 and #3 revealed an excessive amount of dryer lint in the burner assembly compartments. Interview with Director of Nursing (DON) on 07/15/21 at 9:27 A.M. verified the excessive lint build up in the burner assembly compartments in all three dryers. Interview with Director of Support Services (DSS) #30 on 07/15/21 at 1:30 P.M. indicated the facility maintenance staff were supposed to clean out the burner assembly compartments. DSS #30 verified there was no evidence of maintenance staff cleaned out the burner assembly compartments. Review of the facility's policy titled Departmental Maintenance, dated 06/01/11, revealed the facility would vacuum dryer vents twice a shift and vacuum the internal drum areas of dryers at least monthly and as needed. 2. Observation on 07/13/21 at 8:55 A.M. revealed an area directly above the wall air conditioner unit, in the room of Resident #38, which had exposed and damaged dry wall approximately an inch in height and and the full length of the air conditioning unit. In a concurrent interview, Resident #38 stated the area above the air conditioner unit had been that way for the last three or four months and he had asked several staff members, including nurse aides, supervisors, and maintenance, for it to be repaired. Interview on 07/14/21 at 11:53 A.M. with the Director of Support Services (DSS) #30 verified the area above the air conditioning unit had exposed and damaged dry wall and stated it needed to be patched and painted. DSS #30 further stated this was the result of a new air conditioning unit being installed and was unsure of how long ago the unit was installed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 11 of 11