SPRINGFIELD, OH. Resident #108 told staff he felt scared after his roommate yelled threats and hit nursing aides, but administrators at Aventura at Oakwood Village were never notified about the incidents that occurred over several months this year.
The resident said his roommate "was yelling and hitting the aides and he thought if he could do that to them, he could do that to me." Federal inspectors found the facility failed to properly investigate the incidents or follow its own policies requiring review of potential resident-to-resident abuse.
On September 25, Licensed Practical Nurse #248 responded when Resident #108 called out to her in the hallway. She entered the room and heard Resident #107 yelling "shut up, shut up! I'll kick your expletive!" at his roommate.
The nurse said Resident #108 was concerned about his safety. She separated both residents.
But the administrator was never told about the incident. When inspectors interviewed him on December 23, he said he "was never notified of any possible verbal abuse between Resident #107 and Resident #108 on 09/25/25."
The problems went back further. LPN #253 told inspectors that when she cared for Resident #107, "when residents or staff would walk by or was near, Resident #107 when he was angry would swing and hit everyone who was in the way." This included both staff and other residents, she said.
Nobody was hurt in those incidents. But the pattern of aggressive behavior raised concerns about resident safety that were never properly addressed through the facility's reporting system.
Corporate Nurse #207 said she was notified by LPN #248 about a "possible altercation" between the two residents. She asked that the residents be separated and made safe, and said she would get back to the nurse. But she never told the administrator about the incident.
The corporate nurse said "it was during shift change that morning" when she was notified.
Unit Manager #215 said the incident was reported to her and she interviewed Resident #108 that day. The resident told her "he was not comfortable in the room with Resident #107 and he was scared."
The unit manager said the incident was discussed in a team meeting that morning. When she asked Resident #108 what his roommate had said to him, he repeated that Resident #107 "kept telling him to shut up, shut up!" and was "cursing and yelling at him."
Social Worker Director #245 also interviewed Resident #108. The resident told her that Resident #107 "had yelled and hit staff, and not him."
But the social worker never documented the interview in a progress note. She told inspectors she "did not think it was important."
The facility's failure to document and investigate extended to its formal reporting systems. Inspectors reviewed self-reported incidents from August 1 through December 24 and found "no reports were made for the alleged incidents on 08/19/25 and 09/25/25."
The Director of Nursing acknowledged gaps in the response. She said Resident #107 "had developmental delays and was used to one-on-one because where he came from." When inspectors asked about the investigation, she said she "was out of the facility and had to ask to see if anyone had investigated the incident."
The facility's own policy required staff to review situations like this as potential abuse. The policy stated the facility "shall review altercations from resident to resident as a potential situation of abuse."
Staff were supposed to monitor behaviors that could provoke reactions from residents, "including verbal aggressive behavior such as cursing and screaming and physically aggressive behavior including hitting, kicking, throwing objects, and threatening gestures."
The social worker director told inspectors the facility "had not interviewed all residents who had a BIMS of 10 and above, because the facility determined there was no risk for abuse towards other residents."
BIMS refers to a cognitive assessment score. Residents with scores of 10 and above are considered cognitively intact enough to provide reliable accounts of incidents.
The roommate situation was eventually resolved. Resident #108 told inspectors that "the roommate moved to a different room yesterday and the resident stated he was happy about that." He confirmed that his former roommate "did not do anything to me; he did it to the staff."
But the failure to properly investigate and report the incidents violated federal requirements designed to protect nursing home residents from abuse and ensure their safety concerns are taken seriously.
The inspection was conducted in response to a complaint filed with state regulators. The deficiency was classified as causing minimal harm or potential for actual harm to a few residents.
Federal regulations require nursing homes to have systems in place to investigate allegations of abuse and to ensure residents are free from abuse, neglect, and exploitation. Facilities must also report incidents to administrators and state agencies as required.
The breakdown in communication at Aventura at Oakwood Village meant that multiple staff members knew about concerning incidents involving resident safety, but the information never reached facility leadership who could have taken comprehensive action to prevent future problems.
Resident #108's fear of his roommate illustrates how failures in nursing home safety protocols can leave vulnerable residents feeling unsafe in what should be their home.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aventura At Oakwood Village from 2025-12-24 including all violations, facility responses, and corrective action plans.