Trotwood Health & Rehab LLC
4911 Covenant House Drive, Dayton, OH 45426
Trotwood Health & Rehab LLC is a nursing home in Dayton, Ohio. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating2 of 5
- Last standard health inspectionJune 16, 2026 (4 months ago)
- Health citations since November 7, 202292 (Ohio average 31)
- Fines in the past three years1, $53,716 in total
- CMS flagsSpecial Focus Facility candidate, CMS abuse icon
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CMS flags
Special Focus Facility candidate
CMS puts a small number of homes in this program. CMS inspects them more often until they meet the program's exit rules.
CMS abuse icon
CMS adds this icon when it cites a home for abuse that hurt a resident in the past year. It also adds it when it cites a home for abuse that could have hurt someone, in each of the past two years.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 8, 2026
Name
CMS lists a new legal business name for this home.
Ownership
CMS lists this home under a new chain.
Ownership
CMS ownership records list new owners for this home.
CMS update of June 24, 2026
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS abuse icon
CMS added its abuse icon to this home.
Health inspection on June 16, 2026
23 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 23 citations
Citation F0606. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
CMS lists it as corrected on July 16, 2026.
Citation F0607. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for F0607 2 times since 2024.
Citation F0680. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure the activities program is directed by a qualified professional.
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for F0680 2 times since 2025.
Citation F0727. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for F0727 3 times since 2022.
Citation F0804. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on July 16, 2026.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for F0812 3 times since 2024.
Citation F0851. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
CMS lists it as corrected on July 16, 2026.
Citation F0868. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for F0868 2 times since 2022.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 23, 2026.
CMS has cited this home for F0880 3 times since 2023.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for F0761 2 times since 2025.
Citation F0807. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
CMS lists it as corrected on July 16, 2026.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for F0550 3 times since 2024.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for F0558 3 times since 2022.
Citation F0567. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to manage his or her financial affairs.
CMS lists it as corrected on July 16, 2026.
Citation F0569. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
CMS lists it as corrected on July 16, 2026.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on July 16, 2026.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for F0657 3 times since 2022.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on July 16, 2026.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 16, 2026.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for F0686 2 times since 2022.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for F0692 2 times since 2024.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on July 16, 2026.
Citation F0908. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep all essential equipment working safely.
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for F0908 2 times since 2025.
Fire safety inspection on June 16, 2026
16 citationsCMS lists this as a standard inspection.
Show the 16 citations
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on July 1, 2026.
CMS has cited this home for K0291 3 times since 2022.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on July 10, 2026.
CMS has cited this home for K0345 3 times since 2022.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on June 30, 2026.
CMS has cited this home for K0353 2 times since 2024.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on June 26, 2026.
CMS has cited this home for K0521 2 times since 2024.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on July 10, 2026.
CMS has cited this home for K0761 2 times since 2022.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on July 10, 2026.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on July 10, 2026.
CMS has cited this home for K0918 3 times since 2022.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on June 30, 2026.
CMS has cited this home for K0222 2 times since 2024.
Citation K0223. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on July 1, 2026.
Citation K0252. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide at least two remote exits on each floor or fire section of the building.
CMS lists it as corrected on July 10, 2026.
Citation K0293. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on July 10, 2026.
Citation K0355. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on July 10, 2026.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on July 10, 2026.
CMS has cited this home for K0363 2 times since 2024.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on June 30, 2026.
CMS has cited this home for K0511 3 times since 2022.
Citation K0741. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on June 30, 2026.
CMS has cited this home for K0741 4 times since 2022.
Citation K0754. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly sized and located linen or trash receptacles.
CMS lists it as corrected on June 30, 2026.
CMS has cited this home for K0754 3 times since 2024.
CMS update of May 27, 2026
Name
CMS lists a new name for this home. It was GARDEN COURT NURSING AND REHABILITATION CENTER.
Health inspection on April 30, 2026
1 citationCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
47 of 924 Ohio homes (5%) got a citation at the immediate jeopardy level in 2026.
CMS fine of $53,716 on April 30, 2026.
Show the 1 citation
Citation F0600. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on May 1, 2026.
CMS has cited this home for F0600 2 times since 2024.
CMS update of March 25, 2026
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
CMS update of February 25, 2026
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
Staffing
Total nurse staffing reported to CMS went from 2.9 to 2.1 hours per resident per day.
Health inspection on December 22, 2025
4 citationsCMS lists this as a complaint inspection.
Show the 4 citations
Citation F0921. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on January 30, 2026.
CMS has cited this home for F0921 3 times since 2022.
Citation F0561. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS lists it as corrected on January 30, 2026.
Citation F0680. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure the activities program is directed by a qualified professional.
CMS lists it as corrected on January 30, 2026.
Citation F0908. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep all essential equipment working safely.
CMS lists it as corrected on January 30, 2026.
Fire safety inspection on December 18, 2025
4 citationsCMS lists this as a complaint inspection.
Show the 4 citations
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on December 23, 2025.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on December 23, 2025.
CMS has cited this home for K0712 2 times since 2024.
Citation K0754. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly sized and located linen or trash receptacles.
CMS lists it as corrected on December 23, 2025.
Citation K0781. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on December 23, 2025.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
Health inspection on August 22, 2025
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0584. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS lists it as corrected on September 27, 2025.
CMS has cited this home for F0584 8 times since 2024.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 27, 2025.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Health inspection on June 11, 2025
4 citationsCMS lists this as a complaint inspection.
Show the 4 citations
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS lists it as corrected on June 27, 2025.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on June 27, 2025.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on June 27, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on June 27, 2025.
CMS has cited this home for F0755 7 times since 2024.
Health inspection on June 4, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS lists it as corrected on June 27, 2025.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.7 to 3.2 hours per resident per day.
Health inspection on March 26, 2025
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0921. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on April 10, 2025.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on April 10, 2025.
CMS has cited this home for F0759 3 times since 2024.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS lists it as corrected on April 10, 2025.
Health inspection on February 27, 2025
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS lists it as corrected on March 10, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on March 10, 2025.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on March 10, 2025.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Health inspection on January 22, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS lists it as corrected on February 7, 2025.
Health inspection on December 3, 2024
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0745. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS lists it as corrected on December 20, 2024.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on December 20, 2024.
CMS update of October 30, 2024
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
CMS update of September 26, 2024
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS update of August 29, 2024
Fine
CMS changed the fine from March 31, 2022 from $13,892 to $14,198.
Fine
CMS changed the fine from November 7, 2022 from $61,607 to $62,979.
Health inspection on July 23, 2024
19 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 19 citations
Citation F0727. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
CMS lists it as corrected on September 3, 2024.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS lists it as corrected on September 3, 2024.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on September 3, 2024.
CMS has cited this home for F0689 5 times since 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 3, 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 3, 2024.
Citation F0883. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on September 3, 2024.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on September 3, 2024.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on September 3, 2024.
CMS has cited this home for F0580 2 times since 2022.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on September 3, 2024.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on September 3, 2024.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on September 3, 2024.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on September 3, 2024.
Citation F0685. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assist a resident in gaining access to vision and hearing services.
CMS lists it as corrected on September 3, 2024.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on September 3, 2024.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on September 3, 2024.
Citation F0776. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
CMS lists it as corrected on September 3, 2024.
Citation F0791. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or obtain dental services for each resident.
CMS lists it as corrected on September 3, 2024.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on September 3, 2024.
Citation F0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on September 3, 2024.
CMS has cited this home for F0919 3 times since 2024.
Fire safety inspection on July 23, 2024
18 citationsCMS lists this as a standard inspection.
Show the 18 citations
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on September 3, 2024.
CMS has cited this home for E0004 3 times since 2022.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on September 3, 2024.
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on September 3, 2024.
CMS has cited this home for K0324 2 times since 2022.
Citation K0346. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
CMS lists it as corrected on September 3, 2024.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on September 3, 2024.
Citation K0354. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
CMS lists it as corrected on September 3, 2024.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on September 3, 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on September 3, 2024.
Citation K0912. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have power receptacles that are properly grounded.
CMS lists it as corrected on September 3, 2024.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on September 3, 2024.
Citation K0923. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on September 3, 2024.
CMS has cited this home for K0923 2 times since 2022.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on September 3, 2024.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on September 3, 2024.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on September 3, 2024.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on September 3, 2024.
CMS has cited this home for K0372 2 times since 2022.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on September 3, 2024.
Citation K0741. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on September 3, 2024.
Citation K0754. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly sized and located linen or trash receptacles.
CMS lists it as corrected on September 3, 2024.
July 11, 2024
Payment stoppedCMS stopped payment for new admissions from July 11, 2024, for 54 days.
CMS update of June 26, 2024
Fine
CMS changed the fine from March 31, 2022 from $13,000 to $13,892.
Fine
CMS changed the fine from November 7, 2022 from $58,149 to $61,607.
Health inspection on June 6, 2024
7 citationsCMS lists this as a complaint inspection.
Show the 7 citations
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS lists it as corrected on September 3, 2024.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on June 21, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on September 3, 2024.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on September 3, 2024.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on June 21, 2024.
Citation F0770. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely, quality laboratory services/tests to meet the needs of residents.
CMS lists it as corrected on June 21, 2024.
CMS has cited this home for F0770 2 times since 2022.
Citation F0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on September 3, 2024.
Fire safety inspection on June 5, 2024
7 citationsCMS lists this as a complaint inspection.
Show the 7 citations
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on September 3, 2024.
Citation E0006. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct risk assessment and an All-Hazards approach.
CMS lists it as corrected on July 9, 2024.
Citation E0015. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Address subsistence needs for staff and patients.
CMS lists it as corrected on July 9, 2024.
Citation E0025. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Create arrangements with other facilities to receive patients.
CMS lists it as corrected on July 9, 2024.
Citation E0036. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish emergency prep training and testing.
CMS lists it as corrected on July 9, 2024.
Citation K0700. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
CMS lists it as corrected on July 9, 2024.
Citation K0741. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on September 3, 2024.
Health inspection on May 13, 2024
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on September 3, 2024.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on September 3, 2024.
Citation F0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on September 3, 2024.
CMS update of April 25, 2024
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
Health inspection on April 11, 2024
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS lists it as corrected on September 3, 2024.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on September 3, 2024.
CMS update of March 28, 2024
Fine
CMS changed the fine from September 25, 2023 from $118,455 to $76,996.
CMS update of January 31, 2024
Fine
CMS changed the fine from March 15, 2023 from $15,000 to $9,750.
Health inspection on January 9, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on January 26, 2024.
CMS update of December 21, 2023
Fine
CMS changed the fine from November 7, 2022 from $89,460 to $58,149.
Health inspection on October 25, 2023
2 citationsCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
85 of 924 Ohio homes (9%) got a citation at the actual harm level in 2023.
Show the 2 citations
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on November 13, 2023.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 13, 2023.
Health inspection on November 7, 2022
14 citationsCMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
57 of 924 Ohio homes (6%) got a citation at the actual harm level in 2022.
Show the 14 citations
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on January 23, 2023.
Citation F0727. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
CMS lists it as corrected on January 23, 2023.
Citation F0657. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on January 23, 2023.
Citation F0868. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
CMS lists it as corrected on January 23, 2023.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on January 23, 2023.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on January 23, 2023.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on January 23, 2023.
Citation F0625. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
CMS lists it as corrected on January 23, 2023.
Citation F0637. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assess the resident when there is a significant change in condition
CMS lists it as corrected on January 23, 2023.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on January 23, 2023.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on January 23, 2023.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on January 23, 2023.
Citation F0770. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely, quality laboratory services/tests to meet the needs of residents.
CMS lists it as corrected on January 23, 2023.
Citation F0921. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on January 23, 2023.
Fire safety inspection on November 7, 2022
12 citationsCMS lists this as a standard inspection.
Show the 12 citations
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on January 23, 2023.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on January 23, 2023.
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on January 23, 2023.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on January 23, 2023.
Citation K0372. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on January 23, 2023.
Citation K0511. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on January 23, 2023.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on January 23, 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on January 23, 2023.
Citation K0741. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on January 23, 2023.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on January 23, 2023.
Citation E0037. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Establish staff and initial training requirements.
CMS lists it as corrected on December 2, 2022.
Citation E0039. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on December 2, 2022.
CMS star ratings
- 2 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 1 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (937) 837-2651
- Last standard health inspection
- June 16, 2026 (4 months ago)
- Certified beds
- 67
- Residents per day, on average
- 29.4
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Trotwood Health & Rehab LLC
- Chain
- Bao Opco Holdings
- Takes part in
- Medicare and Medicaid
More health citations than the Ohio average (92 vs 31).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- BAO OPCO HOLDINGS LLC5% or greater direct ownership interest · 100% · since 06/30/2025
- SMITHEY, ASHLEY5% or greater indirect ownership interest · 25% · since 06/30/2025
- WOMACK, BRYON5% or greater indirect ownership interest · 75% · since 06/30/2025
- BAO OPCO HOLDINGS LLCOperational/managerial control · not applicable · since 06/30/2025
- OHIO-TWO PROPERTIES LLCOperational/managerial control · not applicable · since 06/30/2025
Show 5 more
- RISE SNF MANAGEMENT LLCOperational/managerial control · not applicable · since 06/30/2025
- BERNER, SUSANOperational/managerial control · not applicable · since 06/30/2025
- DENNY, AMBEROperational/managerial control · not applicable · since 06/30/2025
- SMITHEY, ASHLEYOperational/managerial control · not applicable · since 06/30/2025
- WOMACK, BRYONOperational/managerial control · not applicable · since 06/30/2025
Questions
When was Trotwood Health & Rehab LLC last inspected?
CMS lists June 16, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Trotwood Health & Rehab LLC have?
CMS lists 92 health citations since November 7, 2022. CMS also calls these deficiencies.
Has Trotwood Health & Rehab LLC been fined?
CMS lists 1 fine in the past three years, $53,716 in total.
What is the CMS star rating of Trotwood Health & Rehab LLC?
Its CMS overall star rating is 2 of 5.
Is Trotwood Health & Rehab LLC a Special Focus Facility?
Yes. CMS lists it as a Special Focus Facility candidate.