Aventura at Shiloh Springs

In the surveyor’s words

From the most serious findings on record at Aventura at Shiloh Springs, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 22, 2026

  Based on record review, observations, staff and resident interviews, and review of the facility's smoking policy, the facility failed to adequately assess and supervise residents identified as being supervised smokers to prevent them from smoking while oxygen was in place. This resulted in Immediate Jeopardy and serious life-threatening harm and/or injuries on 04/14/26 when Resident #43 lit a cigarette while wearing oxygen via nasal cannula and sustained burns to his face. On 05/31/25, Resident #43 again lit a cigarette while wearing oxygen and sustained additional burns to his face. This affected one (Resident #43) of three residents reviewed for accident hazards. […]

• Actual harm, isolatedF686Oct 18, 2023

  Based on record review, observation, staff interview, review of the facility policy, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess the resident's skin and failed to timely identify the resident's pressure ulcers until they reached an advanced stage. This resulted in Actual Harm to Residents #32, #39, and #42 who developed pressure ulcers while in the facility which were not identified until they had reached an advanced stage. Resident #42 was not assessed for the risk of pressure ulcer until after the resident developed four pressure ulcers (a stage III pressure ulcer (Full thickness tissue loss. […]

• Actual harm, isolatedF697Apr 11, 2022

  Based on medical record review, observation, resident, staff and pharmacist interview, review of the narcotic count sheet, review of a pharmacy e-mail correspondence and policy review, the facility failed to ensure a resident with a chronic debilitating condition received as needed narcotic pain medication. This resulted in Actual Harm, when staff failed to ensure Resident #10 received as needed (PRN) narcotic pain medication when he reported a sharp stabbing pain at a level nine out of 10 on a pain scale from one to 10 with 10 being the worst pain. The narcotic pain medication was not administered until approximately 16 hours later. This affected one resident (#10) of three residents reviewed for pain. […]

• Actual harm, isolatedF624Aug 20, 2021

  Based on observations, medical record review, policy review, resident interview, Insurance Provider Representative interview and staff interviews, the facility failed to ensure a resident was provided an orderly discharge to meet the mental health and safety of the resident. This resulted in actual psychosocial harm of the resident as evidence by the resident displaying physical signs of red face, being out of breath, crying and verbally stating she was being kicked out. This affected one (#10) of three residents reviewed for discharge planning. The current census is 59. Findings include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF686Feb 4, 2021

  Based medical record review, staff interview, and review of information from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to implement pressure ulcer preventative measurements resulting in the development of avoidable pressure ulcers and the facility failed to complete pressure ulcer treatments as ordered. This resulted in Actual Harm when the resident developed three avoidable unstageable pressure ulcers to the lower extremities. This affected one (#66) out of three residents reviewed for pressure ulcers. The census was 62. Findings include: Review of Resident #66's closed medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. […]