Health inspection·November 30, 2023

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on review of staffing schedules and staff interviews, the facility failed to provide eight hours of continuous Registered Nurse (RN) care seven days a week as required. This had the potential to affect all 47 residents residing in the facility. The facility census was 47. Findings include: Review of the facility staffing schedules for dates 11/21/23 through 11/27/23 revealed there was no Registered Nurse (RN) coverage on 11/25/23 or 11/26/23. On 11/29/23 at 2:57 P.M. an interview with the Administrator confirmed the facility did not have RN coverage on 11/25/23 or 11/26/23. This deficiency represents non-compliance investigated under Complaint Number OH00147602. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366302 If continuation sheet Page 2 of 9 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 366302 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Shiloh Springs 3500 Shiloh Springs Road Trotwood, OH 45426 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review the facility failed to ensure medications were administered as ordered. This affected two (#57 and #33) of four residents reviewed for medication administration. The facility census was 47. Findings include: 1. Review of medical record for Resident #57 revealed admission date of 7/23/23. Medical diagnoses included but were not limited to end stage renal disease and chronic obstructive pulmonary disease. The resident was discharged on 09/29/23. Review of Resident #57's discharge Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. She required extensive assistance for bed mobility, transfers, toileting and supervision for eating. Review of Resident #57's September 2023 Medication Administration Record (MAR) revealed no documentation Carvedilol (hypertension) 25 milligrams (mg) was given at 9:00 P.M. on 09/05/23; Gabapentin (neuropathy)100 mg (pain), Simethicone (gas) 80 mg, Calcium Acetate (phosphate binder) 667 mg at 1:00 P.M.; Atorvastatin (cholesterol) 40 milligrams (mg), Senna- Docusate Sodium (laxative) 8.6-50 mg, two tablets, Carvedilol 25 mg, Gabapentin 100 mg was given at 9:00 P.M. on 09/07/23; Cholecalciferol Calcium (supplement) 25 micrograms (mcg), Lokelma 10 grams (gm) (supplement), Nefedipine 90 mg, Carvedilol 25 mg, Pantoprozole (reflux) 40 mg, Calcium Acetate 667 mg, Gabapentin 100 mg at 9:00 A.M. on 09/08/23; and Atorvastatin 40 milligrams, Carvedilol 25 mg at 9:00 A.M. and Senna- Docusate Sodium (laxative) 8.6-50 mg, two tablets, Carvedilol 25 mg and Gabapentin 100 mg at 9:00 P.M. on 09/26/23. On 11/30/23 at 1:06 P.M. an interview with the Director of Nursing (DON) confirmed Resident #57's medications were not administered as ordered. 2. Review of medical record for Resident #33 revealed admission date of 10/10/23 Medical diagnoses included but were not limited to personal history of bladder cancer, lung cancer, conjunctival edema right eye, ocular pain right eye and DM type 2. The resident remains in the facility. Review of Resident #33's admission MDS dated [DATE] revealed a BIMS score of 11 indicating impaired cognition. He required set up for meals, substantial assistance for toileting, supervision for bed mobility and no documentation for transfers. Review of Resident #33's October 2023 MAR revealed an order for Ofloxacin (antibiotic) Ophthalmic 0.3 percent (%) Solution instill one drop in right eye every two hours while awake. There was no documentation the medication was given on 10/14/23 at 4:00 P.M. and 6:00 P.M., at 6:00 A.M. on 10/15/23 or 12:00 P.M. or 2:00 P.M. on 10/16/22. Additionally, there was an order for Prednisolone Acetate (steroid) one % instill in right eye four times daily was not documented as given on 10/11/23 at 6:00 A.M., 10/14/23 at 6:00 P.M., 10/15/23 at 6:00 A.M., or on 10/16/23 at 12:00 P.M. On 11/30/23 at 1:06 P.M. the DON confirmed Resident #33's eye drops were not administered as physician ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366302 If continuation sheet Page 3 of 9 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 366302 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Shiloh Springs 3500 Shiloh Springs Road Trotwood, OH 45426 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 0755 This deficiency represents non-compliance investigated under Complaint Number OH00148193. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366302 If continuation sheet Page 4 of 9 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 366302 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Shiloh Springs 3500 Shiloh Springs Road Trotwood, OH 45426 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, observations, staff interviews and review of manufacturer instructions, the facility failed to ensure medications were administered as physician orders resulting in three medication errors out of 32 opportunities or a 9.37 percent (%) medication error rate. This affected two (#32, #56) of three residents observed during medication administration. The facility census was 47. Residents Affected - Few Findings include: 1. Review of medical record for Resident #32 revealed admission date of 06/07/22. Medical diagnoses included but were not limited to diabetes mellitus, hypertension and peripheral vascular disease. The resident remains at the facility. Observation on 11/29/23 at 7:42 A.M. of Licensed Practical Nurse #6 during medication administration for Resident #32 revealed an order for Lisinopril (hypertension) five milligrams (mg). LPN #6 stated the Lisinopril medication was not available. Review revealed the medication was last ordered on 10/21/23. A second observation revealed during the administration of 25 units of Levemir (Long acting insulin), LPN #6 took the cap off of the Levemir pen, swabbed the hub with alcohol, applied the needle but did not prime it before she turned the dial to 25. LPN #6 verified she failed to prime the needle prior to drawing up the prescribed 25 units of insulin and the Lisinopril had not been reordered timely. Review of the manufacturer's instruction for Levemir revealed step three was to prime the pen by turning the dose selector to two units and while holding the pen up push and hold the green push button and ensure a drop of insulin appeared at the needle tip. 2. Review of medical record for Resident #56 revealed admission date of 06/22/21. Medical diagnoses included but were not limited to diabetes mellitus type II, depression and dementia. The resident remains at the facility. Review of Resident #56's physician orders revealed an order for Neurontin 100 mg capsule every 12 hours with a start date of 01/21/22. Further review revealed an order for two capsules was discontinued 01/20/22. Observation on 11/29/23 at 8:18 A.M. of LPN #6 during medication administration for Resident #56 revealed two capsules of Neurontin (pain) 100 mg were given. Interview on 11/29/23 at 11:09 A.M. with LPN #6 verified two capsules of Neurontin 100 mg capsules were administered to Resident #56 but the order is for the resident to receive one capsule. This deficiency represents non-compliance investigated under Complaint Number OH00148193. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366302 If continuation sheet Page 5 of 9 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 366302 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Shiloh Springs 3500 Shiloh Springs Road Trotwood, OH 45426 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 0760 Ensure that residents are free from significant medication errors. 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, observation, staff interviews and review of manufacturer instructions, the facility failed to ensure a residents insulin pen was primed according to manufacturer guidelines resulting in a significant medication error. This affected one (#32) of three residents observed for medication administration. Facility census was 47. Residents Affected - Few Findings include: Review of medical record for Resident #32 revealed admission date of 06/07/22. Medical diagnoses included but were not limited to diabetes mellitus and peripheral vascular disease. The resident remains at the facility. Review of Resident #32' quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. He was independent for eating, toileting, transfers and bed mobility. He received seven injections of insulin during the seven day look back period. Observation on 11/29/23 at 7:42 A.M. of Licensed Practical Nurse (LPN) #6 for Resident #32 revealed during the administration of 25 units of Levemir (Long acting insulin), LPN #6 took the cap off of the Levemir pen, swabbed the hub with alcohol, applied the needle but did not prime it before she turned the dial to 25. LPN #6 verified she failed to prime the needle prior to drawing up the prescribed 25 units of insulin. Review of the manufacturer's instruction for Levemir revealed step three was to prime the pen by turning the dose selector to two units and while holding the pen up push and hold the green push button and ensure a drop of insulin appeared at the needle tip. This deficiency represents non-compliance investigated under Complaint Number OH00148193. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366302 If continuation sheet Page 6 of 9 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 366302 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Shiloh Springs 3500 Shiloh Springs Road Trotwood, OH 45426 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 observations, staff interviews, review of dishwasher logs and manufacturers instructions, the facility failed to ensure the dishwasher temperatures and sanitation was being followed as per manufacturer instructions. This had the potential to affect 44 out of 45 residents residing in the facility, two (#39 and #46) residents did not receive their meals from the kitchen. The facility census was 47. Findings include: 1. Observation with Dietary Manager #1 on 11/28/23 at 10:22 A.M. in the facility kitchen of the dishwasher revealed the wash cycle temperature was 86 degrees Fahrenheit (F) and the rinse cycle was 98 degrees F. Several cycles were performed with the wash cycle increasing to 100 degrees F and the rinse cycle to 110 degrees F. On 11/28/23 at 10:22 A.M. Dietary Manager #1 confirmed the dishwasher was not reaching the appropriate temperature. Record review of the dishwasher log revealed for breakfast the wash cycle was 110 degrees F on 11/20/23, 11/22/23 11/26/23; rinse cycle for breakfast was 110 degrees F on 11/20/23; and 115 degrees F on 11/24/23, 11/25/23, 11/26/23; lunch the wash temperature was 110 degrees F on 11/20/23 and 11/21/23; and rinse was 110 degrees F on 11/17/23, 11/18/23, 11/19/23, 11/20 and 11/21/23; dinner rinse temperature was 110 degrees F on 11/13/23 thru 11/20/23 and 115 degrees F on 11/21/23 and 11/22/23. This was verified with Dietary Manager #1 on 11/28/23 at 10:27 A.M. 2. Observation and interview on 11/29/23 at 12:32 P.M. of the dishwasher with the Administrator and Dietary Manager #1 revealed the wash cycle temperature was 122 degrees F and the rinse cycle was 130 degrees F. Observation of the sanitation strip revealed the chlorine bleach strip was 200 parts per million (PPM). Review of the dishwasher log revealed the daily strip readings was documented at 400 PPM for the month of November 2023. Dietary Manager #1 verified the strip documentation listed at 400 PPM was for the three-compartment sink and the chlorine test strips did not reach 400 PPM. Dietary Manager #1 verified there was no documentation the dishwasher sanitation had been checked prior to use. The facility confirmed there has been no food borne illness at the facility and that 45 out of 45 residents receive their meals from the kitchen, there were two (#39 and #46) residents who do not receive meals from the kitchen. Review of the manufacturer's instructions revealed to check the temperature at the end of the cycle for a temperature of at least 120 degrees F. This deficiency represents non-compliance investigated under Complaint Number OH00148290. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366302 If continuation sheet Page 7 of 9 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 366302 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Shiloh Springs 3500 Shiloh Springs Road Trotwood, OH 45426 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of hospital medical records, observations, staff interview, review of manufactures instruction policy review and review of guidelines from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure proper infection control procedures were followed. This affected two residents (#33 and #34) of three residents reviewed for infection control. Facility census was 47. Residents Affected - Few Findings include: 1. Review of medical record for Resident #34 revealed admission date of 6/1/22. Medical diagnoses included but were not limited to encephalopathy, paranoid schizophrenia and diabetes mellitus type II. The resident remains in the facility. Observation on 11/29/23 at 8:49 A.M. of Licensed Practical Nurse (LPN) #11 of medication administration for Resident #34 revealed he was to receive two units of Novolog insulin. LPN #11 removed the Novolog vial from its box and withdrew two units of insulin without cleaning the hub with alcohol. LPN #11 then went to Resident #34's room with the syringe and proceeded to clean his rights upper arm with alcohol and administer the medication subcutaneously without applying gloves. LPN #11 then left Resident #34's room without performing hand hygiene and returned to the medication cart. At 8:54 A.M. LPN #11 verified she did not sanitize the hub of the insulin vial, wear gloves during subcutaneous administration of medication or perform hand hygiene afterwards. Review of the Novolog Vial Instructional Insert, step two on page 47 required to wipe the rubber stop with alcohol. Review of the facility Medication Administration policy revealed #25 documented staff should follow established facility infection control procedures (examples handwashing, antiseptic technique and gloves). 2. Review of medical record for Resident #33 revealed admission date of 10/10/23 Medical diagnoses included but were not limited to personal history of bladder cancer, lung cancer, conjunctival edema right eye, ocular pain right eye and diabetes mellitus type two. The resident remains in the facility. Review of Resident #33's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 11 indicating impaired cognition. He required set up for meals, substantial assistance for toileting, supervision for bed mobility and no documentation for transfers. Review of Resident #33's hospital medical records dated 11/14/23 revealed the resident had a diagnosis of Endophthalmitis (purulent inflammation of the intraocular fluids (vitreous and aqueous) usually due to infection) caused by Methicillin-resistant Staphylococcus aureus (MRSA). Observations of Resident #33's on 11/30/23 at 915 A.M. revealed the resident was no in isolation. Interview on 11/30/23 at 9:15 A.M. with the Administrator revealed Resident #33 needed only standard precautions for his diagnosis of MRSA in his right eye. The Administrator confirmed Resident #33 was not in isolation for the CDC recommendations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366302 If continuation sheet Page 8 of 9 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 366302 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Shiloh Springs 3500 Shiloh Springs Road Trotwood, OH 45426 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 - Few Record review of the facility Infection Prevention and Control Program last revised 07/22 documented isolation protocol for a resident with a communicable disease shall be placed on isolation precautions as recommended by the current Centers for Disease Control Guidelines. Review of the CDC guidelines at https://www.cdc.gov/mrsa/community/patients.html#:~:text=Use%20Contact%20Precautions%20when%20caring,else%20 revealed the CDC recommendation was to use Contact Precautions when caring for patients with MRSA colonized, or carrying, and infected. This deficiency represents non-compliance investigated under Complaint Number OH00148290. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366302 If continuation sheet Page 9 of 9