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Complaint Investigation

Trotwood Health & Rehab Llc

December 22, 2025 · Dayton, OH · 4911 Covenant House Drive
Citations 4
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 December 22, 2025.

Found 4 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

FF0561
Resident Rights Deficiencies
Potential for More Than Minimal Harm

resident care, so heating those areas was not a priority.

These areas included the dining room, Secured Behavioral Unit (100 Hall), chapel, common gathering room, dietary/kitchen and the front administration offices.

The Administrator stated the dining room had been closed for at least two years due to the boiler that controls these areas not being functional.

The Administrator stated the costs for a replacement rooftop boiler/ Heating and Ventilation Air Conditioning (HVAC) system would be more than $900,000, so the facility owners opted to focus on the resident rooms.

This deficiency represents noncompliance investigated under Master Complaint Number 2694504.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/22/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Garden Court Nursing and Rehabilitation Center

4911 Covenant House Drive Dayton, OH 45426

SUMMARY STATEMENT OF DEFICIENCIES

Based on record review, staff interviews, and review of personnel files, the facility failed to ensure the Activities Program was directed by a qualified Activity Director (AD).

This had the potential to affect 32 residents interested in and/or actively participating in activities.

The facility census was 33.Findings include:Review of Resident Council meeting attendance sheets revealed AD #10 did not sign the attendance forms for 09/18/25, 10/23/25 and 11/20/25.

The meetings were facilitated and signed by Activities Aid (AA) #08.Interview on 12/17/25 at 12:45 P.M., Director of Nursing (DON) stated she had not been informed of any concerns expressed by the residents at the Resident Council meetings from September, October or November 2025, and it was the responsibility of the activities staff to keep the facility management informed of any resident concerns.

The DON stated she had no knowledge if AD #10 met the qualifications to be the Activities Director.

Interview on 12/17/25 at 1:15 P.M., AA #08 stated she attended the Resident Council meetings and had been recording the meeting minutes in a binder in the activities office. AA #08 stated she was just informed today that she was responsible for making copies of the meeting minutes and sharing them with the facility management.

Review of the personnel record for the AD #10 on 12/18/25 at 3:00 P.M., revealed she was hired in February 2025 as social services staff.

There was no documented evidence to verify AD #10 had a certification or the appropriate training and/or education to hold the position of AD.

Interview on 12/18/25 at 3:30 P.M., AD#10 stated she was hired in February 2025 as a social services staff and was asked to take over as the Activities Director in May 2025.

AD #10 stated she was going to enroll in the program for Activities Director; however, the facility changed ownership and she couldn't get enrolled. AD #10 verified she didn't meet the requirements to be the Activities Director.

This deficiency represents non-compliance investigated under Complaint Number

  • Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/22/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Garden Court Nursing and Rehabilitation Center

4911 Covenant House Drive Dayton, OH 45426

SUMMARY STATEMENT OF DEFICIENCIES

Review of the facility's policy titled Room Temperature dated revised July 2020 revealed it is the policy of this procedure to maintain safe and comfortable room temperatures inside the range of 71 - 81 degrees F in all resident rooms and resident areas.

Heat and/or Air Conditioning repairs and /or modifications will be completed as soon as possible.The deficiency represents non-compliance investigated under Master Complaint Number 2694504 and Complaint Number

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/22/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Garden Court Nursing and Rehabilitation Center

4911 Covenant House Drive Dayton, OH 45426

SUMMARY STATEMENT OF DEFICIENCIES

Review of the facility's policy titled Room Temperature dated revised July 2020 revealed it is the policy of this procedure to maintain safe and comfortable room temperatures in all resident rooms and resident areas.

Every reasonable attempt will be made to maintain room temperatures in all resident rooms between 71-81 degrees F.The deficiency represents non-compliance investigated under Master Complaint Number 2694504 and Complaint Number 2636823

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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