Health inspection·August 2, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, review of the facility's self-reported incident (SRI) and investigation, and policy review, the facility failed to prevent resident-to-resident physical abuse when a resident struck another resident with a cane, and a third resident came up behind the resident and struck the same resident. This affected one (Resident #19) of three residents reviewed for abuse. The facility census was 51. Findings include: Review of the facility's SRI dated 07/09/24 revealed Resident #19 reported an allegation of physical abuse by two other residents to Licensed Practical Nurse (LPN) #287. Resident #19 reported that Resident #41 struck him across the face while outside in the courtyard and Resident #52 used his hand to hit the back of his head. No injuries noted at time of incident. Review of the investigative notes dated 07/09/24 revealed Resident #41 and #52 denied the allegations. On 07/10/24, Resident #52 confirmed he came up behind Resident #19, swung, hitting him in the face. Review of the addendum to the SRI dated 07/17/24 revealed on 07/16/14, Resident #41 and #52 appeared in the Municipal Court of [NAME] County and the case was set for pretrial. During the course of the investigation conducted by the Parole Officer on 07/17/24, Resident #41 was interviewed and admitted that, in response to Resident #19 pulling on his Hoyer pad, he hit Resident #19 in the face with a cane. When asked why Resident #41 had not disclosed this fact during prior interviews, he said he was done with the matter. 1. Review of the medical record for Resident #19 revealed an admission date of 05/13/24 with diagnoses including combined systolic (congestive) and diastolic (congestive) heart failure, type II diabetes mellitus with hyperglycemia, and acquired absence of left leg above knee. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had moderate cognitive impairment, required supervision with wheelchair mobility, required substantial staff assistance for bed mobility, and was dependent on staff assistance for toileting hygiene, bathing, dressing, and transfers. Review of the care plan dated 06/24/24 revealed Resident #19 had behavior problems, was disruptive to others, resisted care, verbally abusive, wandering. was drug seeking, wandering and was disruptive to other resident's activities of daily living. (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 3 Event ID: 366302 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 08/02/2024 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)