Inspection·December 27, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few investigation and determined the only place the injury could have happened was when she slid down the mechanical lift on 12/13/24. Interview with Medical Director #400 on 12/24/24 at 10:59 A.M. confirmed he spoke to the facility about the injury, but never confirmed the injury occurred while Resident #4 was on the mechanical lift. She did not have osteoporosis or osteopenia, there was no evidence there was an impact during the incident, and the information from the hospital and the x-ray results, found that there was calcification around the fractured area; which would indicate the injury happened a while ago. He could not say exactly when it happened, but he is really confident the injury did not occur on 12/13/24. Review of facility Abuse policy, dated July 2022, revealed the policy had no definition for injury of unknown origin. The policy stated, an injury of unknown origin is investigated to rule out the possibility of abuse. It also stated, the administrator, director of nursing, or designee shall notify the department of health, via the event reporting system electronically, or by phone in the event of the electronic system being unavailable. This deficiency confirmed complaint number OH00160794. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 2 of 4 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 12/27/2024 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to complete a thorough investigation regarding an injury of unknown origin as required. This affected one (Resident #4) of three residents reviewed for injuries. The census was 108. Residents Affected - Few Findings Include: Resident #4 was admitted to the facility on [DATE], diagnoses included fracture of unspecified part of neck of right femur dated 12/18/24, cerebrovascular disease, dementia, anxiety disorder, atrial fibrillation, polyneuropathy, atherosclerotic heart disease, brief psychotic disorder, hyperlipidemia, difficulty walking, degenerative disease of nervous system, hypertension, and cognitive communication deficit. Review of her minimum data set (MDS) assessment, dated 11/08/24, revealed she had a severe cognitive impairment. Review of Resident #4's progress notes, dated 12/13/24, revealed an incident in which Resident #4 was being transferred via mechanical lift. During the process, her arm got caught in the machine and she sustained a small skin tear. In the progress notes, there was no indication she fell, slipped or injured her legs during this incident. There was no documentation about a fall, slip, slide, or lowering of the resident during this incident. Review of Resident #4's progress notes, dated 12/14/24, revealed she was sent to the emergency room to have an examination completed on her left leg/pelvic area due to swelling and discoloration. There was no documented swelling, discoloration or injury to the right leg/hip. Review of Resident #4's hospital documentation, dated 12/18/24, revealed while performing an examination and x-rays, she had a fracture of her right hip. The hospital documentation stated it was an unknown mechanism of injury, and the hospital was considering sending this case to social services for a referral of elder abuse; which was coupled with interview statements from Resident #4's family while in the hospital. There was no documentation to confirm or assist with determining the cause of this injury. Review of Resident #4's facility medical records, dated 11/01/24 to 12/19/24, revealed no documentation to support findings or evidence of how the injury occurred. There was no documentation of a fall or incident that could have contributed to her right hip fracture. Review of facility investigative documents and interview statements, dated 12/14/24 to 12/16/24, revealed there were two interview statements from the nurse and the aide that were directly involved with the incident on 12/13/24, a summary interview statement completed by Administrator, and a timeline of events. None of the interview statements were signed/dated by the person providing the information via written statement. Certified Nursing Aide (CNA) #293's statement stated Resident #4 started sliding down the machine. He got behind her and assisted with lifting her back to a standing position. He called for the nurse and assisted Resident #4 back into her wheelchair. The summary statement confirmed there was an incident in which Resident #4 had a skin tear and bruising on her arm from being caught in the mechanical lift. It confirmed she was sent to the emergency room for swelling and discoloration to her left leg/pelvic area. While performing medical testing on her pelvic area, it was determined that she had a fractured right hip. The facility stated they timely spoke with Medical Director #400 on 12/16/24, and he felt the fracture occurred during the incident on 12/13/24, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 3 of 4 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 12/27/2024 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 0610 they did not investigate the incident further. Level of Harm - Minimal harm or potential for actual harm Interview with Administrator on 12/19/24 at 11:50 A.M. confirmed they did not report the injury to Resident #4 because they had an idea where it came from. She stated they did an initial investigation and determined the only place the injury could have happened was when she slid down the mechanical lift on 12/13/24. She stated they spoke with Medical Director #400, and he confirmed the incident on 12/13/24 was where the injury came from. She confirmed they did not interview any other residents, and only interviewed the two staff involved with the incident. She confirmed it was odd that her right hip was fractured when Resident #4 was sent to the emergency room for her left leg/pelvic area. But they could not find any other documented incident that occurred to support the injury to her right hip. She confirmed she did not have a signed statement from any of the witnesses she interviewed. Residents Affected - Few Interview with Medical Director (MD) #400 on 12/24/24 at 10:59 A.M. confirmed he spoke to the facility about the injury, but never confirmed the injury occurred while Resident #4 was on the mechanical lift. MD #400 stated Resident #4 did not have osteoporosis or osteopenia, there was no evidence there was an impact during the incident, and the information from the hospital and the x-ray results, found that there was calcification around the fractured area; which would indicate the injury happened a while ago. He could not say exactly when it happened, but he was really confident the injury did not occur on 12/13/24. Review of facility Abuse policy, dated July 2022, revealed the policy had no definition for injury of unknown origin. The policy stated, an injury of unknown origin is investigated to rule out the possibility of abuse. Upon receiving an incident or suspected incident of abuse, neglect, misappropriation of resident property, or injury of an unknown source, the administrator/DON/designee will conduct an investigation to include but not limited to the following: interview the person(s) reporting the incident, interview any witnesses to the incident, interview the resident, interview the resident's attending physician and review of the resident's record, interview staff members on all shifts having contact with the resident during the period of the alleged incident, interview the resident's roommate, family members, and visitors, interview other residents to which the accused employee provides care or services, and review all circumstances surrounding the incident. Witness reports shall be in writing or typed. Witnesses will be required to sign and date such reports. The administrator/DON is responsible for receiving and investigating all alleged violations timely, thoroughly, and objectively. The administrator/DON should analyze the report and consult with other resources such as the medical director to investigate medical circumstances, or the social worker, as appropriate. This deficiency confirmed complaint number OH00160794. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365917 If continuation sheet Page 4 of 4