Health inspection·September 27, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Medical record review for Resident #18 revealed an admission on [DATE] with diagnoses including but not limited to kidney failure, acute chronic respiratory failure, congestive obstructive pulmonary disease (COPD), morbid obesity, chronic bronchitis, seizures, asthma, anxiety, depression, sleep apnea, and candidiasis. Review of the quarterly MDS assessment dated [DATE] for Resident #18 revealed an intact cognition. Resident #18 required supervision for eating, and totally dependent on staff for bed mobility, transfers, and toileting. Review of the plan of care for Resident #18 dated 11/18/23 and revised on 06/24/24 revealed resident has altered respiratory status/difficulty breathing related to COPD, chronic respiratory failure with hypoxia, chronic bronchitis, asthma, shortness of breath, anxiety, obstructive sleep apnea with use of BiPap at bedtime. Interventions included will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern and will have no complications related to shortness of breath. Review of the active physician's order for Resident #18 revealed an orders indicating it was okay to use the BiPap from home dated 01/30/24 and an order for oxygen-may wear BiPap full face mask setting 16/5 humidification while sleeping toe times a day for sleep apnea. Review of the treatment administration record for Resident #18 was silent for any documentation related to the application of the mask for Resident #18 at bedtime. Interview on 09/26/24 at 10:37 A.M. with the DON verified the treatment administration record (TAR) was silent for application of the bi-pap device for Resident #18. Additionally, the DON verified Resident #18 had physician orders and when she returned from the hospital they were not added to the electronic health record as orders and should have been. Review of the facility's policy titled CPAP/BiPap Support dated 03/2015 revealed under documentation following should be in the residents medical record, general assessment including vital signs, oxygen saturation, respiratory, circulatory and gastrointestinal status prior to procedure, time CPAP was started and the duration of therapy, mode and settings for the CPAP/BiPap, oxygen concentration and flow and how the resident tolerated the procedure. 3. Medical record review for Resident #15 revealed an admission on [DATE] with diagnosis including not but limited to chronic embolism and thrombosis of deep vein lower, Arnold Chiari Syndrome without spina bifida or hydrocephalus, hypertension, lymphedema, osteoarthritis, insomnia, dermatitis, sleep apnea, bariatric surgery, and asthma. Review of the admission MDS assessment dated [DATE] for Resident#15 revealed resident has an intact cognition. Resident #15 required supervision for eating, supervision for toileting, maximal assistance for bed mobility and transfers was not attempted. Resident #15 is incontinent of bowel and bladder. Resident #15 weighs 394 pounds. Review of the plan of care dated 09/09/24 for Resident #15 revealed resident has potential for pain: related to arthritis, Arnold Chiari Syndrome, history of lymphedema, and decrease in mobility. Interventions include Resident and/or responsible party in treatment plan, update as indicated by change in condition/treatment, Medications as ordered, observe for effectiveness/side effects, update physician as needed regarding effectiveness or need for order change. Assess resident for location, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366302 If continuation sheet Page 2 of 3 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 09/27/2024 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm onset, origin, intensity of, and precipitating factors to pain. Utilize pain scale = 0 or 1-10 (mild, moderate, severe). Observe for pain that may interfere with ability to perform self-care, attempt to increase comfort through nonpharmacological means, i.e., repositioning, quiet environment, guided imagery, music therapy, gentle massage, etc and observe for side effects of narcotic pain medication, sedation, constipation, confusion, respiratory depression. Residents Affected - Few Review of the active physician's orders for Resident #15 revealed an order dated oxycodone oral tablet 5 milligrams one tablet by mouth dated one every eight hours as needed for severe pain dated 09/24/24 at 12:45 P.M. and Tylenol 325 mg two tablets every six hours for pain. Review of the discontinued physicians' orders for Resident #15 revealed an order for Norco tablet 5-325 my one table every eight hours as needed for moderate pain discontinued on 09/24/24. Review of the Medication Administration Record (MAR) for Resident #15 revealed was silent for any Tylenol being administered since 09/21/24. Interview on 09/25/24 with Licensed Practical Nurse (LPN) #28 verified she administered Tylenol to Resident #15 last evening when the resident was asked if she had any pain. Resident #15 stated that her pain was a two or three on a pain scale of 1-10. Interview on 09/26/24 at 7:51 A.M. with LPN #81 verified she administered Tylenol on 09/23/24 at 4:34 P.M. when Resident #15 complained about pain. Additionally, LPN #81 stated Resident #15 stated the pain was at a three or four. Interview on 09/26/24 at :37 A.M. with DON verified the Resident #15 did not have any Tylenol recorded on the MAR since 09/21/24 and the nurses that stated they administered the pain medication would be coming into the facility and making a late entry regarding the administration of the medication. Additionally, the DON verified Resident #15 did not have a order independent of the pain medication for pain monitoring every shift and had added that to Resident #15's medication profile on 09/25/24. Review of the facility policy titled Charting and Documentation, dated 08/24 stated the following information is to be documented in the medical record, observations, medication administration, treatment or services, changes in condition and events, accidents involving the resident. This deficiency represents non-compliance investigated under Complaint Numbers OH00157965, OH00157841 and OH00157354. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366302 If continuation sheet Page 3 of 3