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Complaint Investigation

Trotwood Health & Rehab Llc

August 22, 2025 · Dayton, OH · 4911 Covenant House Drive
Citations 2
CMS Rating 2/5
Beds 67
Provider ID 365364
Healthcare Facility
Trotwood Health & Rehab Llc
Dayton, OH  ·  View full profile →
Inspection Summary

Trotwood Health & Rehab LLC in DAYTON, OH — inspection on August 22, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0584
Resident Rights Deficiencies
Potential for More Than Minimal Harm

Observation of water temperatures on 08/19/25, beginning at 11:40 A.M. with the Administrator, revealed Resident #22's bathroom sink hot water temperature was 73.5 degrees F, Resident #23's bathroom sink hot water temperature was 66.0 degrees F, the 200-hall shower room hot water temperature was 72.5 degrees F, Resident #31's bathroom sink hot water temperature was 69.8 degrees F, Resident #9's bathroom sink hot water temperature was 68.0 degrees F, and Resident #2's bathroom sink hot water temperature was 65.0 degrees F.

The Administrator verified the water temperatures.

Review of an estimate for the replacement of the hot water heater revealed it was dated 07/23/25.

Further review revealed no evidence the facility took action related to the acceptance of the estimate to make needed repairs.

This deficiency represents noncompliance investigated under Master Complaint Number 2589044 and Complaint Number 2566950.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/22/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Garden Court Nursing and Rehabilitation Center

4911 Covenant House Drive Dayton, OH 45426

SUMMARY STATEMENT OF DEFICIENCIES

Observation on 08/18/25 from 12:31 P.M. through 12:50 P.M. revealed [NAME] #220 prepared the three-compartment sink to wash dishes.

The first sink held water poured from a 33 gallon pan that had boiling water from the stove. [NAME] #220 poured pot and pan detergent directly from a one-gallon jug into the water in the first sink, without measuring the amount.

The second sink contained plain hot water for rinsing.

The third sink had cold water. [NAME] #220 proceeded to pour just under one-half of a full gallon sized jug of sanitizer into the water in the third sink.

Further observation revealed [NAME] #220 tested the sanitation level in the third sink and the test strip read 400 parts per million (ppm), which was a dark blue color on the test strip. [NAME] #220 verified there was too much sanitizer in the water, noting the color on the test strip should be more of a green color, and stated he had no measuring devices to ensure appropriate chemicals were used to ensure safe sanitation of the dishes.

Interview on 08/22/25 at 3:50 P.M. with Dietary Manager (DM) #944 revealed the hot water in the kitchen went out approximately one month ago. DM #944 stated the device to measure the chemical solutions for the three-compartment sink had been broken for a long time and staff did not have a way to measure cleaning or sanitation solutions to ensure safe and effective cleaning of the dishes. DM #944 confirmed dietary staff washed dishes in the three-compartment sink since the kitchen had no hot water to use the dishwasher.

This deficiency represents noncompliance investigated under Master Complaint Number 2589044.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DAYTON, OH, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Trotwood Health & Rehab LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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