Aventura at Carriage Inn: Medication Records Falsified - OH
Federal inspectors documented the contradiction during a complaint investigation completed October 21, 2025. The facility, located at 5040 Philadelphia Drive, had 63 residents at the time.
The resident at the center of the finding, identified in inspection records as Resident #15, was admitted to the facility on April 8, 2025, with diagnoses including atrial fibrillation, malignant prostate cancer, and pneumonia. His physician had ordered Diltiazem 120 milligrams once daily, a medication used to manage heart rate in atrial fibrillation. The order included a specific instruction: hold the dose if the resident's systolic blood pressure dropped below 110.
On the morning of October 20, Licensed Practical Nurse #30 checked Resident #15's blood pressure and got a reading of 104/66. The systolic number was below the threshold. She withheld the Diltiazem and disposed of it. That part was by the book.
What happened next was not.
At 1:03 that afternoon, LPN #30 signed the medication administration record indicating she had given Resident #15 his Diltiazem. The record showed no blood pressure recheck. There was no documentation that his pressure had recovered enough to safely receive the medication, no note explaining the morning hold, and no record of what actually happened to the dose. Just a signature, timestamped more than three hours after the medication had already been thrown away.
Inspectors noted that Resident #15, assessed in July 2025, had intact cognition and needed moderate help with daily activities. He was aware of his surroundings. Whether he knew his medication record had been falsified, the inspection report does not say.
The Director of Nursing confirmed the core facts when inspectors interviewed her the following afternoon. She said she had called LPN #30 directly and that the nurse told her she had administered the Diltiazem at 1:03 P.M., along with other medications ordered for that hour. The Director of Nursing confirmed that the physician's hold parameters were in place, confirmed the morning blood pressure reading, and confirmed there was no documented blood pressure recheck before the 1:03 entry.
She confirmed, in other words, that the record showed a medication given that had been discarded hours earlier.
What the Director of Nursing did not explain, and what the inspection report does not resolve, is how LPN #30 accounted for administering a dose she had already disposed of. The nurse told her supervisor she had given it. The sharps container told a different story.
Diltiazem is a calcium channel blocker. In a patient with atrial fibrillation, it slows the heart rate. The physician's hold parameter existed because administering it when blood pressure is already low can drop pressure further, causing dizziness, falls, or worse. The order to withhold at a systolic below 110 was a protective instruction. The nurse followed it correctly in the morning. What she recorded in the afternoon suggests she either gave a medication she did not have, or she gave it without checking whether his blood pressure had risen enough to make it safe, then signed the record without documenting a recheck either way.
The inspection was triggered by a complaint, filed under Complaint Number 2640037. Inspectors rated the harm level as minimal harm or potential for actual harm. One of two residents reviewed for medication administration was affected.
Resident #15 had atrial fibrillation, cancer, and pneumonia. He relied on the people charting his care to write down what they actually did.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aventura At Carriage Inn from 2025-10-21 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
AVENTURA AT CARRIAGE INN in DAYTON, OH was cited for violations during a health inspection on October 21, 2025.
Federal inspectors documented the contradiction during a complaint investigation completed October 21, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.