Aventura At Oakwood Village
Inspection Findings
F-Tag F0759
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, observations and staff interviews, the facility failed to ensure the medication error rate did not exceed five percent (%). Three errors occurred within 27 opportunities for an error rate of 11.11%. This affected two (#20 and #21) of two residents reviewed for medication administration. The facility census was 108.Findings include:1. Review of the medical record for Resident #20 revealed an admission date of 11/13/25. Diagnoses included chronic kidney disease and atrial fibrillation. The admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #20 had intact cognition. Review of
the physician's orders dated 11/14/25 revealed an order for oxybutynin (treats overactive bladder) 10 milligrams (mg) extended release. Give one tablet daily until 11/17/25.Observation on11/18/25 at 8:56 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #100 was administering medications to Resident #20. LPN #100 administered oxybutynin chloride extended release (overactive bladder) 10 milligrams (mg) to Resident #20.Interview on 11/18/25 at 11:42 A.M. with LPN #100 verified the Oxybutynin order was no longer active. 2. Review of the medical record for Resident #21 revealed an admission date of 03/05/25. Diagnoses included stroke, autistic disorder and peripheral vascular disorder. Review of the physician orders dated 11/02/25 revealed an order for Vitamin B6 (vitamin) one tablet by mouth daily and there was no documented dosage. A second order was for Tylenol 1,000 milligrams (mg) by mouth every six hours as needed for pain.Observation on 11/18/25 at 9:27 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #101 administered medications to Resident #21. LPN #101 administered Vitamin B6 100 mg and one Tylenol 325 mg tablet to Resident #21.Interview on 11/18/25 at 11:28 A.M. with LPN #101 verified there was no dosage prescribed for the Vitamin B6 supplement and acknowledged the physician should be called to clarify the order. LPN #101 also verified she had administered one 325 mg Tylenol table when the order was for 1,000 mg.This deficiency represents non-compliance investigated under Complaint Number 2666022.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
AVENTURA AT OAKWOOD VILLAGE in SPRINGFIELD, OH inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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 SPRINGFIELD, 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 AVENTURA AT OAKWOOD VILLAGE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.